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DISEASES 
OF  THE  INTESTINES 


BY 

Dr.   I.   BOAS 

SPECIALIST    FOR    GASTRO-INTESTINAL    DISEASES    IN    BERLIN 

AUTHORIZED  TRANSLATION  FROM  THE  FIRST  GERMAN  EDITION 
WITH    SPECIAL    ADDITIONS 

BY 

SEYMOUR   BASCH,  M.  D. 

NEW    YORK    CITY 


"  Nec  ultra,  nee  infra  scire' 


IV [TH  FORTY-SEl/EN  ILLUSTRATIONS 


NEW    YORK 

D.    APPLETON     AND     COMPANY 

1 90 1 


CoPYRIßHT,    1901, 

By   D.   appleton   AND   COMPANY. 


AUTHOR'S   PREFACE   TO   THE   AMERICAN 
TRANSLATION 


It  affords  me  great  pleasure  to  make  a  few  introductory 
remarks  to  this  translation  of  my  recently  published  Diagnostik 
und  Therapie  der  Darinkrankheiten. 

When  the  present  book  was  written,  the  interest  of  the  pro- 
fession in  the  pathology  of  the  alimentary  tract  had  already  become 
very  great.  Owing  to  the  ease  with  which  diseases  of  the  oesopha- 
gus and  stomach  could  be  investigated,  these  had  been  exten- 
sively studied.  Because  of  their  inaccessibility  and  the  difficulty 
of  judging  the  effect  of  treatment,  our  knowledge  of  affections 
of  the  intestine  (exclusive,  perhaps,  of  the  rectum)  was  still  very 
meagre. 

JSTotvdthstanding  that  the  classical  publications  of  Woodward 
and  Nothnagel,  and  the  studies  in  ptomainology  and  the  pathology 
of  metabolism  have  done  much  to  further  our  knowledge  of  in- 
testinal diseases,  we  have  advanced  but  little  since  the  days  of 
Henoch,  Bamberger,  von  Leube,  and  their  contemporaries. 

Internal  medicine  must  acknowledge  a  debt  of  gratitude  to 
surgery,  for  the  surgeon  has  contributed  most  to  the  progress 
that  has  been  made.  Our  knowledge  of  appendicitis,  intestinal 
obstruction  and  stenosis,  and  benign  and  malignant  tumours  has 
been  greatly  enriched  by  the  results  obtained  from  surgical  treat- 
ment, and  this  progress  is  still  going  on.  It  is  universally  con- 
ceded that  the  American  profession  has  contributed  much  toward 
this  end,  and  in  many  parts  of  this  work  I  have  acknowledged 
this  indebtedness.  Numerous  references  to  American  authors  will 
be  found  throughout  the  book. 


jy  DISEASES  OP  THE   INTESTINES 

It  mii^ht  be  inferred  from  this  that  my  treatise  contains  little 
that  is  unknown  in  America,  but  I  trust  that  the  American  reader 
will  find  some  useful  diagnostic  and  therapeutic  hints  in  the  fol- 
lowing pages. 

I  desire  to  express  raj  thanks  to  my  former  assistant,  Dr.  Basch, 
for  having  undertaken  and  carried  to  a  successful  conclusion  the 
work  of  translation. 

I  trust  that  the  American  edition  will  meet  with  the  same 
success  that  has  attended  the  original  in  Germany.  If  it  will 
aid  the  practitioner  in  solving  some  of  the  difficult  problems  in 
intestinal  pathology  and  assist  him  in  the  treatment  of  his  patients, 
the  author  will  feel  that  his  labours  have  not  been  in  vain. 

I.  Boas. 

Berlin,  February,  1901. 


TRANSLATOE'S  PREFACE 


The  popularity  which  Dr.  Boas's  treatise  has  enjojed  abroad, 
and  the  absence  in  the  Enghsh  language  of  any  detailed  and 
exhaustive  work  on  intestinal  diseases,  have  led  to  the  publication 
of  the  present  translation. 

The  book  is  intended  more  especially  for  the  requirements  of 
the  general  practitioner,  but  on  account  of  the  exhaustive  and  con- 
cise description  of  physiologico-chemical  processes  and  laboratory 
methods,  it  must  also  prove  of  value  to  other  scientific  investigators. 

Additions  have  been  made  to  the  chapters  on  Appendicitis  and 
Hydrotherapeutics,  a  special  account  given  of  the  intestinal  gases, 
and  brief  notes  added  in  various  parts  of  the  book.  These  are 
indicated  by  [  ]. 

1  wish  to  express  my  sincere  thanks  to  Dr.  S.  JSTeuhof,  of  this 

city,  for  valuable  assistance  in  the  preparation  of  this  work  for 

the  press,  and  to  the  publishers,  D.  Appleton  and  Company,  for 

the  many  courtesies  extended  to  me. 

S.  Basch. 
48  East  Sixty-third  Street, 
New  York,  March,  1901. 


PREFACE   TO   THE   FIRST   GERMAN  EDITION 


The  present  treatise  is  the  final  volume  of  the  author's  work  on 
the  diagnosis  and  treatment  of  the  diseases  of  the  gastro-intestinal 
tract.  In  this  book  I  have  closely  followed  along  the  lines  laid 
down  in  my  earlier  work  on  Diseases  of  the  Stomach.  It  has 
been  my  aim  throughout  to  meet  the  requirements  of  the  general 
practitioner. 

Without  neglecting  those  diseases  which  are  generally  met  with 
in  hospital  practice,  I  have  given  special  prominence  to  the  affec- 
tions which  the  private  practitioner  is  called  upon  to  treat — e.  g., 
intestinal  catarrhs  and  ulcers,  duodenal  ulcer,  chronic  constipation, 
rectal  diseases,  intestinal  neuroses,  etc.  I  have  devoted  no  space  to 
the  discussion  of  intestinal  parasites,  and  would  refer  the  reader 
to  standard  text-books  of  medicine  or  the  numerous  monographs 
on  the  subject. 

In  many  of  the  chapters  I  have  drawn  upon  my  own  experi- 
ence as  gained  both  in  a  large  polyclinic  and  hospital  practice.  I 
hope  that  I  have  been  able  to  add  some  new  and  j)erhaps  valuable 
facts  to  the  pathology  and  treatment  of  intestinal  diseases. 

"While  physical  methods  have  been  so  thoroughly  studied  that 
only  technical  differences  remain,  examination  of  the  fgeces  has 
heretofore  been  very  much  neglected.  Whereas  putrid  sputa, 
badly  smelling  lochia,  offensive  secretions  of  uterine  cancer  in 
themselves  no  longer  offer  serious  objection  to  examination,  most 
physicians  cannot  accustom  themselves  to  the  analysis  of  the 
intestinal  dejecta.  This  may  in  part  be  due  to  the  circumstance 
that  deductions  can  be  drawn  only  after  repeated  careful  exami- 
nations.    This  latter  consideration  should  not,  however,  influence 


PREFACE  TO   THE  FIRST  GERMAN  EDITION  vii 

the  conscientious  physician,  for  urine  and  sputum,  too,  are  very 
often  examined  with  negative  results. 

Since  many  intestinal  diseases  may  require  surgical  interference 
at  any  moment,  I  have  felt  it  necessary  in  a  number  of  chapters  to 
define  my  position  in  this  respect.  As  an  internal  practitioner  I 
have  naturally  little  sympathy  with  extreme  radical  measures,  and, 
with  increasing  experience,  beheve  with  conservative  surgeons 
that  we  have  almost  reached  the  limits  of  possibility  in  intestinal 
surgery. 

As  in  diseases  of  the  stomach,  abdominal  surgery  has  also  made 
considerable  advance  within  the  last  decade  in  diseases  of  the  in- 
testines. If  the  medical  practitioner  wishes  to  keep  abreast  of 
progress  he  must  follow  these  advances  with  the  greatest  con- 
scientiousness, and  consider  carefully  the  changes  made  from  time 
to  time  in  surgical  technic,  noting  the  results  obtained  there- 
from. Should  he  have  the  good  fortune  to  be  associated  with 
a  skilful  abdominal  surgeon,  he  should  use  every  opportunity  to 
witness  operations  upon  the  intestine.  This  sharpens  the  judg- 
ment, demonstrates  the  knowledge  or  ignorance  of  surgery,  and 
indicates  to  us,  even  better  than  cumbersome  and  frequently  col- 
oured statistics,  the  manner  in  which  we  must  proceed  in  serious 
cases.  As  I  have  already  stated  in  another  place,  I  must  again 
emphasize  that  the  indications  for  operative  procedures  in  diseases 
of  the  stomach  and  the  intestines,  as  well  as  of  the  liver  and  gall 
bladder,  is  a  matter  which  rests  mainly  with  the  medical  practi- 
tioner. He  should  bear  the  responsibility  for  the  operative  inter- 
ference, while  the  surgeon  should  be  responsible  for  the  technic. 
The  placing  of  the  responsibility  in  one's  hands  implies  the 
greatest  confidence  on  the  part  of  the  patient  and  his  family,  and 
the  medical  practitioner  can  only  accept  such  responsibility  when 
he  has  recognised  the  disease  in  time,  and  is  in  a  position  to  judge 
whether  or  not  a  surgical  procedure  is  indicated,  and  with  what 
prospects  of  success. 

In  discussing  these  difficult  and  very  important  questions,  I 
have   agreed   in   most   respects  with  the  views   of   early  writers. 


yi-ji  DISBASES   OF   THE   INTESTINES 

In  stating  my  views  I  have  endeavoured  to  include  theirs.  In 
this  connection  I  feel  called  upon  to  express  mj  admiration  for 
the  epoch-making  treatise  on  intestinal  diseases  of  Professor 
Nothnagel,  of  Yienna,  and  my  appreciation  of  his  classical 
studies  on  the  physiology  and  pathology  of  the  intestines. 

Finally,  I  take  great  pleasure  in  acknowledging  my  thanks  to 
my  publisher,  Mr.  George  Thieme,  of  Leipsic,  for  the  careful 
preparation  of  the  work.  I  desire  also  to  thank  Miss  Paula 
Günther,  of  Berlin,  and  my  former  assistant.  Dr.  Reitzenstein, 
of  Nürnberg,  for  the  excellent  execution  of  the  drawings. 

The  Author. 

Berlin,  July,  1899. 


CONTENTS 


PAGE 

Author's  preface  to  the  American  translation iii 

Translator's  preface t 

Preface  to  the  first  German  edition vi 


INTRODUCTOEY 

CHAPTER 

I. — Preliminary  anatomical  and  histological  remarks         ...  1 

Appendix.     Displacements  of  various  segments  of  the  intestines  20 

II. — Preliminary  physiological  and  physiologico-chemical  remarks    ,  24 

[The  intestinal  gases] 46 


PART  I 

GENERAL  DIVISION 

III. — The  history 55 

IV. — The  examination  of  the  patient 67 

Appendix.     The*  employment  of  Röntgen  rays  in  the  diagnosis  of 

intestinal  diseases 88- 

V. — Examination  of  the  f^ces 90 

VI. — Diagnostic   value  of   the   examination  of   stomach   contexts   in 

intestinal  diseases 129 

VII. — Diagnostic    value    of    urinary    examinations   in    intestinal    dis- 
eases    132 

GENERAL   THERAPEUTICS   OF  INTESTINAL  DISEASES 

VIII. — The  dietetic  treatment  of  intestinal  diseases        ....     139 
IX. — The  hydrotherapeutics  of  intestinal  diseases  [including  mineral 

WATERS   OF    THE    UnITED    StATES] 158 

X. — Massage.    Electro-  and  hydrotherapeutics  in  intestinal  diseases     170 
XL — Injections  (enemata.  intestinal  lavage,  and  douches),  inflation, 

and  gastric  lavage  in  intestinal  diseases 177 

XII. — Medicinal  treatment  of  intestinal  diseases 186 

ix 


DISEASES  OF   THE    INTESTINES 


PART   II 
SPECIAL  DIVISION 

CHAPTER  PAGE 

XIII. — Acute  and  chronic  intestinal  catarrh 205 

XIV. — Habitual  constipation.     Displacements  of  the  intestines  .        .  240 

XV. — ulcers  of  the  intestines .        .        .  261 

XVI. — Round  ulcer  of  the  duodenum 280 

XVII. — Intestinal  neoplasms 296 

XVIII. — Intestinal  stenosis  and  intestinal  obstruction    ....  342 

XIX. — Typhlitis,  perityphlitis  (appendicitis) 430 

[Brief  resume  of  the  American  views  on  appendicitis]      .        .  466 

Appendix.     Sigmoiditis  and  pericolitis 473 

XX. — Diseases  of  the  rectum »        =        .        .  482 

XXI. — Nervous  diseases  of  the  intestines        ......  521 

List  of  subjects ;        .        .        .  543 

List  of  authors 557 


LIST   OF   ILLUSTRATIONS 


FIGURE  PAGE 

1.  Anterior  view  of  the  abdominal  viscera 3 

2.  Perpendicular  section  of  adult  human  jejunal  mucous  membrane    .         .  6 

3.  Intestinal  epithelium 7 

4.  Section  of  mucous  membrane  of  human  duodenum 7 

5.  Surface  of  mucous  membrane  of  the  small  intestine 9 

6.  Cross  section  of  intestinal  mucous  membrane 9 

7.  Section  of  mucous  membrane  of  the  small  intestine  thi'ough  a  Peyer's 

patch 10 

8.  Anterior  view  of  the  abdominal  viscera  after  removal  of  the  jejunum  and 

ileum 11 

9.  Opening  of  the  ileum  into  the  large  intestine 13 

10.  Male  pelvic  organs,  viewed  from  the  i-ight  side 17 

11.  Herzstein's  rectoscope 81 

13.     Spirals  of  undigested  meat  fragments  in  faeces 98 

13.  Different  vegetable  substance  found  in  faeces 114 

14.  Fatty  stools,  showing  a  large  amount  of  fatty  acid  crystals       .         .         .  115 

15.  Fatty  soaps  in  fasces 116 

16.  Normal  and  degenerated  epithelial  cells  from  the  mucous  shreds  of  a 

case  of  membranous  enteritis 118 

17.  Faeces  from  a  case  of  chronic  enteritis,  showing  sarcina^   ....  130 

18.  Bacillus  butyricus  {Clostridium  biityricum)  stained  with  iodin         .         .  132 

19.  Charcot-Leyden  crystals  from  fiBces 138 

20.  Yellow  calcium  salts  from  fasces 135 

31.  Bismuth  crystals  from  fjeces 126 

32.  [Position  of  hands  and  direction  of  movements  in  abdominal  massage]    .  171 

23.  Electric  rectal  tube 174 

24.  Vermiform  appendix  in  contact  with  the  under  surface  of  the  liver         .  357 

25.  Vermiform  appendix  lying  behind  the  right  lobe  of  the  liver   .         .         .  257 

36.  Double  looping  of  the  transverse  colon 358 

37.  Double  looping  of  the  sigmoid  flexure 858 

38.  Multiple  looping  of  the  sigmoid  flexure 359 

39.  Tuberculosis  of  the  ca?cum 365 

30.  Multiple  polypi  of  the  rectum 335 

31.  Ulcer  of  the  duodenum,  with  secondary  stenosis  of  the  second  portion 

and  dilatation  of  the  flrst  portion 351 

33.  Strangulation  by  a  broad  peritoneal  band  passing  between  two  adjacent 

coils  of  ileum 371 

33.    Strangulation  of  small  intestine  by  a  solitai-y  band  attached  at  either  end 

to  the  mesentery 371 


xü  DISEASES   OF   THE  INTESTINES 


PAGE 


FIGURE 

34.  Strangulation  of  a  small  intestinal  coil  by  a  long  ligamentous  strand       .  372 

35.  Internal  strangulation  of  an  intestinal  coil  by  a  strand  passing  from  the 

omentum  or  transverse  colon  to  the  anterior  abdominal  wall        .         .  372 

36.  Internal  strangulation  of  a  loop  of  small  intestine  by  a  Meckel's  diver- 

ticulum coiled  about  it    .        .         .     ^ 373 

37.  Sigmoid  flexure  showing  a  tendency  to  volvulus  formation       .         .         .  377 

38.  A.  Type  rectum  en  arriere.     B.  Type  rectum  en  avant     ....  377 

39.  Schematic  drawing  to  illustrate  a  knotting  together  of  ileum  and  sig- 

moid flexure 379 

40.  Schematic  drawing  to  illustrate  a  simple  intestinal  invagination      .         .  383 

41.  Ileo-cfecal  intussusception 385 

^.     Complete  rectal  fistula 488 

43.  Incomplete  internal  rectal  fistula 488 

44.  Incomplete  external  rectal  fistula 488 

45.  Tubercular  anal  and  rectal  ulcer,  with  hemorrhoidal  nodule     .         .         .  495 

46.  Rectal  support      . 508 

47.  Peristaltic  restlessness  of  the  small  intestines  and  descending  colon         .  526 


INTRODUCTORY 


CHAPTER  I 

PRELIMINARY  ANATOMICAL  AND  HISTOLOGICAL  REMARKS* 

The  intestinal  canal  is  that  portion  of  the  alimentary  tract  which 
is  situated  below  the  pylorus.  The  small  intestine  has  for  its  main 
function  the  digestion  of  unassimilated  food ;  the  large  intestine 
serves  for  the  reception  and  propulsion  of  undissolved  and  waste 
food  products  until  their  expulsion  from  the  body.  Occasionally 
the  large  bowel,  especially  the  rectum,  is  called  upon  to  digest  and 
absorb  nourishment,  but  this  vicarious  process  of  nutrition  is  not 
adequate  to  support  life  a  long  time. 

SMALL    INTESTINE 

The  small  intestine,  a  small,  thin-walled  tube  about  1  metres 
long,  extends  from  the  pylorus  to  the  right  iliac  fossa,  where,  after 
becoming  extremely  convoluted,  it  finally  opens  into  the  large  intes- 
tine. It  is  divisible  into  three  portions,  which  vary  as  regards  length 
and  calibre — viz.,  duodenum,  jejunum,  and  ileum. 

1.  Duodenum 

The  duodenum,  about  30  centimetres  long  and  4  to  6  centimetres 
wide,  is  the  widest  and  at  the  same  time  least  movable  portion  of 
the  small  intestine.  It  describes  a  horse-shoe  curve,  the  convexity 
of  which  is  directed  toward  the  right  and  downward,  its  concavity 
embracing  the  head  of  the  pancreas.  Owing  to  its  peculiar  form 
the  duodenum  is  divided  into  three  segments :  superior  horizontal 
portion  {pars  horizontalis  stoperior)^  a  descending  portion  {2)ars 
descendens)^  and  an  inferior  ascending  portion  {pars  horizontalis 
inferior)  {seu  oblique  ascendens,  seu  transversa). 

The  pars  horizontalis  superior.,  the  shortest  division  (5  centi- 
metres long),  commences  at  the  pylorus  at  the  level  of   the  first 

*  In  writing  the  present  chapter  use  has  been  made  of  the  more  popular  text- 
Ujooks  of  anatomy,  especially  A.  Rauber's  Lehrbuch  der  Anatomie,  Leipzig,  1892. 


DISEASES  OP  THE  INTESTINES 


lumbar  vertebra.  From  here  it  passes  slightly  upward,  backward, 
and  to  the  right,  thus  gaining  the  right  side  of  the  vertebral  column. 
Ascending  to  the  neck  of  the  gall  bladder,  it  then  bends  abruptly 


Fig.  1.— Antekior  View  of  the  Abdominal  Viscera  ("/s). 
(The  liver  is  turned  upward,  thereby  drawing  the  stomach  and  duodenum  slightly 
upward  and  to  the  right.)  i,  left  lobe  of  liver;  2,  lobus  quadratus;  S,  right  lobe  of  liver; 
4,  gall  bladder ;  5,  round  ligament  of  liver  ;  6,  fundus  of  stomach ;  7,  greater  curvature  ;  8; 
lesser  curvature ;  9,  horizontal  portion  of  duodenum  ;  10,  descending  portion  of  duodenum  ; 
il,  lesser  omentum ;  i^,  spleen;  i,?,  jejunum  ;  i.^,  ileum  ;  i5,  ascending  loop  of  ileum  ;  Iff, 
ca3cum ;  17,  vermiform  appendix ;  18,  ascending  colon ;  19,  hepatic  fle.xure  ;  20,  transverse 
colon ;  21,  splenic  fle.xure ;  22,  descending  colon ;  23,  sigmoid  flexure  ;  24,  bladder.     ( Rauber.) 

dowuM^ard,  and  is  continued  as  the  pars  descendens.  The  superior 
horizontal  portion  is  invested  by  peritoneum,  both  anteriorly  and 
posteriorly,  and  behind  is  in  relation  with  the  hepatic  duct  and  the 


PRELIMINARY  ANATOMICAL  AND   HISTOLOGICAL   REMARKS       3 

blood-vessels  passing  to  the  liver  (the  portal  vein  and  the  hepatic 
artery).     This  part  frequently  is  found  stained  with  bile. 

The  fars  descendens  duodeni,  which  begins  at  the  neck  of  the 
gall  bladder,  is  twice  as  long  as  the  first  portion.  It  passes  almost 
vertically  downward  in  front  of  the  right  kidney  and  to  the  right  of 
the  vertebral  column,  about  as  far  as  the  third  or  fourth  lumbar 
vertebra.  The  transverse  colon  crosses  at  right  angles  in  front  of 
it.  The  common  bile  duct  opens  into  the  descending  portion  just 
before  the  latter  merges  into  the  pars  horizontalis  inferior.  The 
duct  descends  behind  the  left  border  of  the  descending  portion,  and 
then,  together  with  the  pancreatic  duct,  which  accompanies  it  for  a 
short  distance,  penetrates  the  wall  of  the  gut.  Thus  a  kind  of 
longitudinal  swelling  is  formed,  at  whose  lower  end  the  common 
opening  of  the  ducts  is  situated.  This  opening  is  frequently  hol- 
lowed out — the  diverticulum  Vateri. 

The  lower  transverse  portion — the  pc(/rs  horizontalis  inferior.^ 
or,  more  correctly,  the  pars  ascendens — equals  or  even  exceeds  in 
length  the  portion  just  described.  It  ascends  obliquely  from  right 
to  left,  reaching  the  left  side  of  the  second  lumbar  vertebra,  where, 
making  a  sharp  bend — the  flexura  duodeno  jejunaUs — it  merges 
into  the  jejunum.  It  passes  behind  the  origin  of  the  transverse 
mesocolon  and  the  mesentery,  while  the  abdominal  aorta  and  the 
vena  cava  lie  in  front  of  this  division.  A  short,  fibrous,  muscular 
strand,  derived  from  the  left  crus  of  the  diaphragm  (the  suspensory 
muscle  of  the  duodenum),  retains  this  portion  of  the  duodenum  in 
place.  Thus,  in  contrast  to  the  stomach,  and  especially  to  the  large 
intestines,  the  duodenum  is  usually  fixed  ;  nevertheless,  as  a  result 
of  marked  distention  and  traction,  it  may  descend  to  a  greater  or 
lesser  degree. 

2.  jEJinsruM  and  Ileum 

The  jejunum  and  ileum,  which  together  have  received  the  name 
of  intestimitn  niesentericum,  merge  into  each  other  without  any 
sharply  defined  line  of  separation.  Formerly  the  term  jejunum  was 
applied  to  those  portions  of  the  small  intestines  which  lie  in  the 
umbilical  region  and  in  the  left  iliac  fossa,  while  the  ileum  included 
the  portions  in  the  right  half  of  the  abdomen,  in  the  right  iliac  fossa, 
and  in  the  pelvis.  There  are  no  marked  differences  in  the  structure 
of  these  two  divisions.  According  to  Hyrtl,  three  fifths  of  the 
small  intestine  below  the  duodenum  constitute  the  jejunum  and  the 
remaining  two  fifths  the  ileum.     The  great  mobility  of  the  small 


4  DISEASES   OF   THE  INTESTINES 

intestines  does  not  permit  of  any  constant  position  of  the  coils,  but 
in  general  the  upper  coils  lie  more  transversely  and  the  lower  more 
vertically.  This  mobility,  however,  is  of  the  greatest  practical  im- 
portance ;  it  allows  of  the  adaptation  of  the  intestines  to  the  most 
■diverse  conditions  of  the  abdominal  cavity,  and  also  of  their  gliding 
aside  when  the  cavity  is  filled  with  serous  or  other  effusions. 

The  mesentery,  which  binds  the  ileo-jejunum  to  the  spinal  col- 
umn, is  of  great  importance.  Fan-shaped,  it  spreads  from  its  origin 
{radix  meseriterii)  and  lies  in  many  folds.  Its  edges  are  attached  to 
the  small  intestines  by  means  of  a  small  slip,  the  mesenteric  border. 

Blood-vessels,  lymphatics,  and  nerves  run  between  the  two  layers 
of  the  mesentery.  They  enter  the  wall  of  the  intestines  at  the 
mesenteric  border  and  terminate  at  the  opposite  free  side. 

The  arteries  supplying  the  duodenum  are  derived  partly  from 
the  coeliac  axis  and  partly  from  the  superior  mesenteric  artery,  as 
follows :  The  coeliac  axis  gives  off  the  hepatic  artery,  which  sup- 
plies the  liver.  The  gastro-duodenal  branch  of  the  hepatic  artery 
passes  behind  the  stomach  at  the  junction  of  the  pylorus  and  the 
horizontal  portion  of  the  duodenum,  and  in  turn  gives  off  the  pan- 
creatico-duodenalis  superior,  which  supplies  the  duodenum  and  the 
pancreas.  In  addition  to  the  latter  vessel  the  duodenum  is  also 
supplied  by  the  pancreatico-duodenalis  inferior,  a  branch  of  the 
superior  mesenteric  artery.  The  latter  vessel  passes  beneath  the 
pancreas,  while  its  branch  (the  pancreatico-duodenalis  inferior) 
winds  upward  and  to  the  right,  passing  between  the  lower  half  of 
the  duodenum  and  the  head  of  the  pancreas,  and  ultimately  anasto- 
moses with  the  pancreatico-duodenalis  superior. 

The  jejunum  and  ileum  are  supplied  by  branches  of  the  superior 
mesenteric  {artericB  hitestinales).  They  pass  between  the  layers  of 
the  mesentery,  dividing  forklike,  and  finally  form  a  rich  capillary 
network  throughout  the  entire  intestinal  wall.  The  lower  end  of 
the  ileum  alone  receives  its  blood  supply  from  branches  of  the  ileo- 
colic (colica-dextra),  which  latter,  in  part,  also  supply  the  cfiecum  and 
the  vermiform  process,  and,  in  conjunction  with  the  superior  mesen- 
teric, the  lower  end  of  the  ileum. 

Thus,  we  see,  a  dense  network  of  the  most  delicate  blood-vessels 
extends  throughout  the  entire  mesentery  of  the  small  intestines, 
piercing  the  muscular  layers  of  the  gut  and  penetrating  to  the  sub- 
mucosa,  where  a  second  network  is  formed  which  supplies  the 
mucous  membrane,  the  folds,  vilH,  and  glands  of  the  mucosa. 

The  veins  which  carry  the  blood  from  the  intestines  into  the 


PRELIMINARY  ANATOMICAL   AND   HISTOLOGICAL   REMARKS       5 

portal  vein  have  a  course  differing  somewhat  from  their  correspond- 
ing arteries  ;  viz.,  the  branches  corresponding  to  the  gastro-duodenal 
artery  (i.  e.,  the  gastro-epiploica  and  the  pancreatico-duodenal)  empty 
into  the  superior  mesenteric  vein. 

The  lyinjyhatics  may  be  divided  into  two  sets,  a  superficial  and 
a  deep.  The  superficial  originate  in  the  muscularis  (subserous 
lymphatics),  while  the  deeper  originate  in  the  mucous  membrane, 
the  villi,  and  the  solitary  follicles  (submucous  lymphatics).  Both 
sets  unite  at  the  mesenteric  border  of  the  small  intestine  and  then 
pass  between  the  layers  of  the  mesentery.  Owing  to  their  physio- 
logical significance,  they  are  called  lacteals. 

The  nerves  of  the  small  intestines  are  derived  chiefly  from  the 
superior  mesenteric  plexus  of  the  sympathetic.  The  hepatic  plexus, 
an  offshoot  of  the  coeliac  plexus,  gives  branches  to  the  duodenum. 
Furthermore,  the  small  intestine  is  supplied  by  the  abdominal  por- 
tion of  the  vagus ;  viz.,  the  anterior  and  posterior  gastric  plexuses. 
The  nerves,  which  are  for  the  most  part  non-medullated,  accompany 
the  branches  of  the  sujDcrior  mesenteric  artery  to  the  intestinal  wall, 
and  there  form  a  subserous  meshwork ;  they  then  pierce  the  longi- 
tudinal muscular  layer,  forming  between  the  latter  and  the  circular 
layer  a  network  consisting  of  numerous  multipolar  cells — the  mes- 
enteric plexus  of  Auerbach. 

From  the  latter  delicate  nerve  branches  supply  the  muscularis  ; 
others  penetrate  the  circular  muscular  layer  to  the  submucosa, 
where  they  form  the  submucous  or  Meissner  nerve  plexus — a  very 
fine  network  of  nerves  containing  small  ganglion-cell  groups. 
Bundles  of  nerve  fibres  pass  from  this  plexus  to  the  muscularis 
nmcosse  and  to  the  muscularis  of  the  villi,  and  are  then  lost  in  the 
mucous  membrane. 

Histology  of  the  Small   Intestines 

The  wall  of  the  small  intestines  is  composed  of  four  coats  : 
tunica  serosa,  muscularis,  submucosa,  and  mucosa  (Fig.  2,  page  6). 

The  serous  coat  (peritoneum),  as  has  been  already  mentioned 
(page  2),  does  not  uniformly  invest  the  small  intestines.  Practically 
speaking  (and  this  is  especially  of  surgical  interest),  the  descending 
portion  of  the  duodenum  is  covered  only  upon  its  anterior  surface 
by  the  serous  layer,  while  the  superior  and  inferior  horizontal  por- 
tions are  inclosed  by  both  folds  of  the  mesocolon.  The  serous  layer 
is  most  adherent  at  the  free  border  of  the  intestines,  and  but  loosely 
adherent  at  the  mesenteric  border. 
2 


6 


DISEASES   OF   THE  INTESTINES 


The  muscularis  of  the  intestines  consists  of  two  layers  of  un- 
striped  muscle  fibres:  a  thick  inner  circular,  and  a  thin  external 
longitudinal  layer.  Toward  the  ileum  the  layers  gradually  become 
thinner. 

Artifacts 
Perpendicular  section  of  the  villi^ 


Epithelium- 


Tunica 
propria- 


Tunica 
propria. 


Muscularis 
mucosce- 


Submucosa,''    ~       \  /  '  j 

Intestinal  glands  Oblique  section  of  intestinal  glands 

Fig.  2. — Perpendicular  Section  of  Adult  Human  Jejunal  Mucocs  Membrane  (  x  80). 
During  fixation  the  tunica  propria  of  the  villi  retracted  and  became  separated  from  the 
epithelium,  thus  causing  a  space  at  a  and  a  tear  at  h.     The  dark  spots  in  the  villi,  at  the 
right-hand  side  of  the  figure,  are  goblet  cells.     (After  Stöhr.) 

The  submucosa  is  composed  of  loose  retiform  tissue,  and  sup- 
ports the  above-described  numerous  blood  and  nerve  plexuses. 
The  muscularis  mucosm  consists  of  smooth  muscle  fibres,  an  inner 
circular  and  an  outer  longitudinal  layer.  From  it  fibres  pass  per- 
pendicularly and  inwardly,  almost  reaching  the  apices  of  the  intes- 
tinal villi.  By  their  contraction  they  may  cause  shortening  of  the 
villi. 

The  epithelium  of  the  mucosa  (Fig.  3)  consists  of  a  single  layer 
of  cylindrical  cells.  We  may  distinguish  two  forms :  cylindrical 
epithelium  with  a  basement  membrane,  and  the  goblet  cells.  The 
significance  of  this  basement  membrane  is  still  a  matter  of  contro- 
versy.    According  to  the  latest  investigations,  we  must  here  recog- 


PRELIMINARY  ANATOMICAL  AND   HISTOLOGICAL  REMARKS 


A  B 

Fig.  3. — Intestinal  Epithelium  ( x  560). 
A,  goblet  cells  of  rabbit   (at  x  protrusion  of  mucus) ; 
B,  portion  of  a  section  of  human  small  intestine  ;  b,  a  goblet 
cell  between  cylindrical  cells.     (Stöhr.) 


nise  a  very  delicate  skeletal  framework  with  free  interspaces ;  througli 
tliese  latter,  very  fine  protoplasmic  prolongations  of  the  epithelial 
cells  can  be  thrust 
and  again  withdrawn. 
Thus,  the  chief  seat  of 
absorption  is  evident- 
ly in  the  basement 
membrane  of  the  epi- 
thelial cells.  The 
goblet  cells  have  an 
oval,  not  infrequent- 
ly a  gobletlike,  form, 
the  upper  (free)  part 
being  more  or  less  filled  with  mucus,  which  results  from  a  proto- 
plasmic metamorphosis,  while  the  nucleus  lies  at  the  base  of  the 
cell.      They   have   no    basement  membrane,   but   have   a   sharply 

defined  opening  at  their  free  border, 
through  which  the  mucus  is  poured 
into  the  intestines.  Leucocytes  are 
present  in  varying  numbers  between 
the  epithelial  cells. 

The  tunica  projpria  consists  main- 
ly of  reticular  connective  tissue,  with 
here  and  there  numerous  leucocytes. 
Owing  to  the  size  and  number  of  the 
glands  of  the  large  intestines,  the 
tunica  propria  is  insignificant  form- 
ing little  more  than  the  intervening 
substance  between  the  glands  and  a 
narrow  strip  of  basement  substance. 
In  the  small  intestines  the  tunica  pro- 
pria forms  numerous  cylindrical  pro- 
jections from  the  inner  surface  of  the 
gut,  the  projections  being  0.5  to  0.7 
millimetre  in  height  and  0.1  to  0.2 
millimetre  in  width ;  these  are  the 
so-called  intestinal  villi  (Fig.  4).  In 
the  duodenum  they  are  leaflike  in 
shape.  To  a  certain  extent  their 
functions  are  like  those  of  the  roots  of  trees,  inasmuch  as  they  dip 
directly  into  the  nutritive  material  in  the  intestinal  canal,  and  absorb 


ah  a. 

Fig.  4. — A.  Section  of  Mucoits  Mem- 
brane   OF    Human    Duodenum 
(xlO). 
a,  villi ;  b,  basement  substance  of 
the  mucous  membrane  ;  c,  Brunner's 
glands ;  d',  deepest  layers  of  the  sub- 
mucous tissue. 

B.  Transverse  Section  of  Isolated 
Glands. 
a  a,  with  lumen ;  J,  without  lu- 
men.    (Eauber.) 


8  DISEASES  OF  THE  INTESTINES 

all  of  it  thereof  tliat  can  be  taken  up  (A.  Kauber).  The  total  num- 
ber of  villi  is  estimated  as  over  ten  million.  Each  villus  contains  a 
central  chyle  space,  or  villous  sinus,  which  is  a  club-shaped  expan- 
sion of  the  lacteals  of  the  intestinal  mucous  membrane,  and  is  lined 
with  endothelium.  The  larger  villi  contain  several  of  these  spaces. 
The  blood-vessels  of  the  villi  spread  out  in  the  reticular  tissue 
between  the  external  and  internal  endothelium.  This  rich  capillary 
network  may  cause  erection  of  the  villi,  while  the  previously  men- 
tioned offshoots  from  the  muscularis  mucosee  cause  their  rhyth- 
mical contractions.  TJius  the  villi  act  as  simple  and  yet  complete 
suction  pumps.  The  villi  are  most  numerous  in  the  duodenum, 
gradually  diminishing  in  number  in  the  ileum.  Each  villus  receives 
its  blood  supply  from  one  or  more  arterial  branches  which,  dividing, 
form  a  meshwork  near  the  epithelium,  from  which  meshwork  the 
corresponding  vein  arises. 

A  similar  arrangement,  intended  for  the  greatest  possible  absorp- 
tion and  a  uniform  distribution  of  nutritive  material,  is  found  in  the 
so-called  folds  of  Kerckring  {valvulce  conniventes  Kerchringii). 
These  occupy  one  half  to  two  thirds  of  the  transverse  circumference 
of  the  mucous  membrane,  and  are  found  close  together  in  the  upper 
third  of  the  small  intestine.  They  are  absent  in  the  upper  third  of 
the  transverse  portion  of  the  duodenum.  They  number  about  eight 
hundred,  and  the  distances  between  the  individual  folds,  according 
to  Sappey,  average  15  millimetres.  In  the  upper  third  of  the  small 
intestines  their  height  and  the  intervals  between  them  are  uniform  ; 
in  the  middle  they  diminish  both  in  height  and  breadth,  and  finally 
disappear  in  the  lowermost  coils  of  the  ileum. 

Glands  form  another  constituent  of  the  mucous  membrane  of 
the  small  intestines.  The  liver  and  the  pancreas  should  be  reckoned 
among  these,  since  their  secretions  form  an  important — indeed,  an 
indispensable — part  of  the  intestinal  juices.  Since  these  are  inde- 
pendent abdominal  organs,  their  structure  can  not  be  entered  into 
here.  We  have  already  discussed  the  openings  of  the  ducts  of  these 
glands  (page  3).  The  glands  proper  of  the  intestines  are  of  two 
varieties:  secretory  and  agminated.  The  first  variety  includes 
Brunner's  and  Lieberkiihn's  glands;  the  second  variety  includes 
the  so-called  solitary  blind  follicles  and  Peyer's  agminated  glands 
(Peyer's  patches).  Brunner's  glands  (Fig.  4),  which  are  found 
almost  exclusively  in  the  upper  part  of  the  duodenum,  are  spread 
over  an  area  of  from  8  to  10  centimetres  from  the  pylorus.  They 
are  conglomerate  tubular  glands  whose  bodies  lie  within  the  sub- 


PRELIMINARY  ANATOMICAL   AND    HISTOLOGICAL   REMARKS       9 


Fig.  5. — Surface  of  Mucous  Membrane  of 
THE  Small  Intestine. 
i,  openings  of  Lieberkiihu's  glands ;  f ,  villi. 
(Eauber.) 


mucosa.  Their  terminal  portions  are  lined  with  cylindrical  cells 
having  a  lightly  coloured  granular  protoplasm  and  an  oval  nucleus 
which  lies  near  the  periphery.  The  cells  are  best  found  by  dissect- 
ing away  the  muscularis  from  without. 

In  structure,  Lieberkiihu's  glands  (Figs.  5  and  6)  resemble  closely 
the  tubular  glands  of  the  stomach ;  they  are  evidently  the  true  se- 
creting glands  of  the  small  in- 
testines. They  are  present  in 
enormous  numbers  throughout 
the  mucous  membrane  of  both 
small  and  large  intestines.  They 
are  club-shaped  and  rounded  off 
both  above  and  below.  Like  the 
glands  of  the  stomach,  they  are 
also  seldom  branched.  They 
measure  from  0.3  to  OÄ  milli- 
metre in  length,  their  total  num- 
ber being  estimated  by  Sappey 
at  forty  to  fifty  million.  Ac- 
cording to  Drasch,  the  glands 

are  surrounded  by  a  fine  network  of  capillaries"  and  nerves.  They 
generally  terminate  in  circular  openings  between  the  villi,  and  when 
viewed  with  a  lens  give  the  mucous  membrane  a  honeycomb  appear- 
ance. As  is  well  known,  the  solitary  lymph  nodules  (solitary  fol- 
licles) are  also  met  with  in  the 
oesophagus  and  stomach.  They 
are  quite  uniformly  distributed 
throughout  the  surface  of  the 
small  intestine.  They  have  an 
elongated  oval  shape  and  are  as 
large  as  millet  seeds,  but  under 
pathological  conditions  may  reach 
the  size  of  a  pea,  or  even  larger. 
They  extend  deeply  below  the  sub- 
mucosa.  As  regards  their  finer 
structure,  this  consists  of  adenoid 
tissue  and  usually  contains  a  ger- 
minal centre.  The  leucocytes  so 
frequently  present  in  the  follicles 
may  pass  into  the  lymphatic  vessels  or,  by  piercing  the  epithelium, 
may  enter  into  the  lumen  of  the  intestines. 


Fig.  6. — Cross  Section  of  Intestinal 
Mucous  Membrane  (  x  150). 
Showing  Lieberkühn's  glands  with 
their  epithelial  cell-lining  embedded  in 
the  adenoid  tissue  of  the  raucous  mem- 
brane, from  which  the  cells  are  partially 
absent.    (Rauber.) 


10 


DISEASES  OF   THE   INTESTINES 


Peyer's  patclies  occur  in  the  ileum  as  elongated  plaques,  from 
2  to  10  centimetres  in  length  and  from  1  to  3  centimetres  in 
breadth,  their  long  axis  corresponding  to  that  of  the  gut.  They 
are  never  situated  at  the  mesenteric  border.  Occasionally  they  are 
met  with  in  the  jejunum,  or  even  higher  up,  in  the  duodenum. 
Usually  twenty  to  thirty  such  plaques  are  present.  They  are  made 
up  of  groups  of  soHtary  nodules  spread  out  over  a  flat  surface  (Fig. 
7) ;  occasionally  they  become  flattened  from  pressure.  The  mucous 
membrane  covering  the  glands  is,  as  a  rule,  thrown  into  folds,  but 
it  has  no  viUi.  Yilh  are,  however,  frequently  present  as  flat  folds 
upon  the  intervening  elevations  (Henle). 


Y\v,.  7.— Section  of  Ml-cocs  Membrane  of  the  Shall  Intestine  through  a  Peyer's 
Patch,  the  Chyle  Vessels  being  Injected. 
a,  villi;   c,  follicles:   fZ,  projections  of  the  latter  toward  the  surface;  </,  //.,  «,  lymphatic 
network  around  the  follicles  ;  h^  efferent  blood-vessels.     (Frey.) 


The  branches  of  the  chyle  vessels  form  numerous  meshes  about 
the  glands,  and  communicate  with  them  by  means  of  very  delicate 
projections.  These  projections  permit  the  passage  of  newly  formed 
lymph  cells  into  the  lymph  channels,  for  Peyer's  patches  are  breed- 
ing places  for  lymph  cells  (A.  Raul)er). 


LARGE   INTESTINE 

The  large  intestine  (Fig.  8,  page  11),  the  lower  division  of  the 
intestinal  canal,  commences  in  the  right  iliac  fossa,  and  thence 
ascends  along  the  right  posterior  wall  of  the  abdomen  to  the  right 
hypochondrium.  Here  it  comes  in  contact  with  the  under  surface 
of  the  liver,  and,  bending  to  the  left,  passes  transversely  and  slightly 
upward  to  the  spleen.  There,  in  the  left  hypochondrium,  it  bends 
downward  and  descends  along  the  left  side  of  the  abdomen  to  the 
left  iliac  fossa,  and  thence  onward  into  the  jDelvis.     The  large  intes- 


PRELIMINARY  ANATOMICAL  AND   HISTOLOGICAL   REMARKS     H 

tine  measures  about  1.5  metres  in  length  (according  to  Sappey, 
exactly  1.68  metres),  and  varies  in  diameter  from  5  to  8  centimetres. 
Its  diameter  gradually  diminishes  from  the  csecum  downward.    The 


Fig.  8. — Anterior  View  of  the  Abdominal  Viscera  after  Eemoval  of  the  Jejunum 

AND  Ileum  ( x  Ys). 
(Liver  and  stomach  are  turned  up,  the  jejunum  and  ileum,  excepting  their  two  ends, 
removed,  the  mesentery  is  retained),  i,  left  lobe  of  liver ;  2,  lobus  quadratus  ;  <?,  right  lobe 
of  liver ;  4-,  gall  bladder ;  5,  round  ligament  of  liver ;  6,  fundus  of  stomach  ;  7,  greater  curva- 
ture; ^,  lesser  curvature  ;  S,  pylorus  ;  iO,  duodenum  ;  i7,  pancreas  ;  I^,  spleen;  iJ,  jejunum; 
14-,  mesentery ;  i5,  ileum ;  16,  csecum ;  i7,  vermiform  appendix ;  18,  ascending  colon  ;  19, 
hepatic  flexure ;  20,  transverse  colon ;  21,  splenic  flexure ;  22^  descending  colon ;  23,  sigmoid 
flexure ;  ;g.^,  bladder.     (Eauber.) 

dimensions  just  given  may  be  greatly  altered  by  pathological  con- 
ditions. 

The  large  intestine  differs  from  the  small  not  only  in  calibre  but 


12  DISEASES  OP   THE  INTESTINES 

also  l)y  having  tliree  narrow  longitudinal  bands  of  unstriped  muscle 
fibres  iligamenta  or  tcenia  coli).  These  begin  in  the  csecum  at  a 
point  corresponding  to  the  insertion  of  the  vermiform  appendix. 
Through  them  the  intestine  is  thrown  into  numerous  sacculi  {hcmstra 
coli),  separated  from  one  another  by  deep  folds  {sulci  transversi). 
These  folds  and  pouches  do  not  exist  in  the  rectum,  hence  the 
latter  is  readily  distinguished  from  the  other  portions  of  the  large 
intestine. 

As  regards  its  course,  the  large  intestine  is  divisible  into 

1.  A  bhnd,  pouchlike  commencement,  the  ccecum,  with  the 
vermiform  appendix. 

2.  An  ascending  portion,  colon  ascendens. 

3.  A  transverse  portion,  colon  transvcTsum. 

4.  A  descending  portion,  colon  descendens. 

5.  The  portion  within  the  left  iliac  fossa,  flexura  sigmoidea 
{S.  romamim). 

6.  The  rectum. 

Each  of  these  subdivisions  requires  separate  consideration. 

1.    C^CUM    AND    YeKMIFOEM    ApPENDIX 

The  blind  gut  is  that  portion  of  the  large  intestine  lying  imme- 
diately below  the  termination  of  the  ileum.  Its  length  is  subject  to 
wide  fluctuations,  variously  estimated  from  -±  to  12  centimetres. 
According  to  Henle,  the  average  length  is  5.5  centimetres.  Its 
width  almost  equals  its  length.  The  ciBCum  lies  in  the  right  iliac 
fossa  above  the  middle  of  Poupart's  ligament,  and  is  in  contact 
anteriorly  with  the  abdominal  wall.  When  immoderately  long,  it 
may  extend  into  the  small  pelvis.  In  the  majority  of  cases  the 
caecum  is  completely  invested  by  peritoneum  (the  mesocsecum). 
This  would  account  for  its  great  freedom  of  motion  and  the  fre- 
quency with  which  it  forms  one  of  the  contents  of  femoral  and 
inguinal  hernia.  In  rare  cases  the  peritoneum  is  absent  from  its 
posterior  surface.  Attached  to  the  anterior  surface  of  the  lower 
middle  division  of  the  caecum  we  find  the  vermiform  appendix,  an 
organ  of  extreme  practical  importance,  but  of  whose  physiological 
functions  we  at  present  know  nothing.  It  varies  in  length  from  2 
to  20  centimetres ;  its  width  is  about  -J  to  1  centimetre.  Usually  it 
is  spiral-shaped,  and  is  directed  from  the  right  iliac  fossa  toward  the 
border  of  the  small  pelvis,  or  it  may  even  dip  into  the  small  pelvis. 
It  has  a  small  mesentery  {rnesenteriolum)  and,  like  the  caecum,  it 
is  freely  movable.     The  appendix  is  hollow  up  to  its  apex,  and 


PRELIMINARY  ANATOMICAL  AND   HISTOLOGICAL   REMARKS     13 


communicates  with  the  caecum  through  a  small  opening,  the  ostiura 
processus  vermiformis.  This  opening  is  sometimes  guarded  by  a 
small  crescentic  fold,  the  valvxila  processus  vermiformis. 

The  terminal  opening  of  the  small  intestine  is  found  at  the  junc- 
tion of  the  caecum  and  ascending  colon.  This  opening,  which  leads 
from  the  ileum  into  the  large 
intestine,  is  guarded  bj  a  valve 
formed  of  two  crescentic  folds, 
the  valvula  coli  or  Bauhini 
(Fig.  9).  The  two  folds,  superior 
and  inferior,  are  united  at  their 
ends,  but  in  the  centre  form  an 
aperture  at  right  angles  to  the 
long  axis  of  the  colon.  I^ormal- 
Ij  this  valve  permits  the  passage 
of  contents  from  the  small  intes- 
tines into  the  large,  but  not  con- 
versely. It  will  not  even  allow 
the  passage  of  gases  insufflated 
into  the  large  intestine.  Only 
the  combination  of  extreme 
pressure  with  a*  relative  insuffi- 
ciency of  the  valve,  such  as  oc- 
curs in  paresis  of  the  intestinal 
wall,  can  eifect  a  passage  of  in- 
testinal contents  into  the  ileum. 


Fig.  9. — Opening  of  the  Ileum  into  the 
Laege  Intestine. 
(Perpendicular  section  through  the  caecum 
and  ileo-csecal  valve.)  p.  «.,  vermiform  ap- 
pendix, whose  opening  into  the  caecum  is 
visible.     (Gegenbaur.) 


2.  Ascending  Colon 

The  ascending  colon  passes  almost  vertically  upward  from  the 
right  iliac  fossa  to  the  under  surface  of  the  liver,  upon  which  latter 
surface  it  produces  the  impressio  colica.  In  the  region  of  the  gall 
bladder  the  ascending  segment  of  the  colon  leaves  the  posterior  ab- 
dominal wall  and  passes  sharply  forward  and  to  the  left,  thus  becom- 
ing more  superficial ;  then,  forming  the  hepatic  flexure,  the  gut 
continues  on  as  the  transverse  colon.  The  hepatic  flexure  of  the 
colon  is  connected  with  the  liver  by  a  short,  taut  band,  the  ligamen- 
tum  hepatico-colicum.  In  front,  the  ascending  colon  is  in  relation 
with  coils  of  the  small  intestines;  behind,  with  the  lateral  border 
of  the  quadratus  lumborum  and  with  the  transversalis  abdominis,  as 
well  as  with  the  lower  anterior  surface  of  the  right  kidney.  There- 
fore it  is  possible  to  have  nephro-colic  abscesses  without  peritonitis. 


l^  DISEASES   OF   THE  INTESTINES 

The  remainder  of  the  ascending  colon  is  completely  surrounded  by- 
peritoneum. 

3.  Tkaistsveese  Colon 

The  transverse  colon  passes  from  the  right  hypochondrium  up- 
ward and  to  the  left  behind  the  anterior  abdominal  wall  to  the  left 
hypochondrium ;  then,  bending  acutely,  it  continues  as  the  descends 
ing  colon.  The  angle  thus  formed  is  known  as  the  splenic  flexure. 
At  this  flexure  the  colon  leaves  its  superficial  position  and  passes 
sharply  downward  and  backward.  The  flexure  is  connected  with 
the  diaphragm  by  the  ligamentuhi  jjhrenico-coliciiin.  The  trans- 
verse colon  is  provided  with  a  very  long  mesentery,  the  mesocolon 
transversum,  and  is  therefore  freely  movable.  This  point  will 
again  be  referred  to. 

•i.  Descending  Colon 

The  descending  colon  passes  from  the  sjilenic  flexure  vertically 
downward  through  the  left  hypochondriac  and  lumbar  regions  to 
the  left  iliac  fossa,  where  it  forms  an  S -shaped  fold,  the  sigmoid 
ßexure.  The  splenic  flexure  is  in  contact  above  with  the  spleen. 
Anteriorly,  the  descending  colon  is  covered  for  the  most  part  with 
coils  of  small  intestine.  The  descending  colon,  like  the  ascending, 
has  no  mesentery  of  its  own,  and  it  therefore  is  not  freely  mov- 
able. It  is  invested  only  laterall}"  and  anteriorly  by  peritoneum. 
Its  posterior  surface  is  in  relation  with  the  costal  portion  of  the 
diaphragm,  with  the  left  kidney,  the  transversalis  abdominis  and 
quadratus  lumborum  muscles,  as  well  as  with  the  iliac  fascia,  to  all 
of  which  structures  it  is  connected  by  loose  connective  tissue. 

5.  Sigmoid  Flexure  (S.  Romanum)  (Fig.  10,  page  17) 

This  is  formed  by  a  double  loop  of  the  colon,  and  has  the  ap- 
pearance of  an  inverted  S.  We  may  distinguish  an  upper  (colon) 
segment  whose  convexity  is  directed  toward  Poupart's  ligament,  and 
a  lower  (rectal)  segment  which  projects  more  or  less  into  the  pelvis. 
As  a  rule,  the  transition  to  rectum  occurs  at  the  sacro-iliac  synchon- 
drosis. 

The  sigmoid  flexure  is  entirely  covered  by  peritoneum,  which 
forms  a  rather  long  mesentery,  the  mesocolon  flexuroB  sigmoidece. 
On  this  account  the  flexure  is  freely  movable.  In  the  newly  born 
the  sigmoid  flexure  has  a  very  long  mesentery,  and  it  may  therefore 
lie  on  the  right  side  near  the  caecum,  especially  if  defecation  has 
not  yet  occurred  and  the  flexure  is  still  filled  with  meconium. 


PRELIMINARY   ANATOMICAL   AND  HISTOLOGICAL   REMARKS     15 

Blood-vessels,  Lymphatics,  and  Nerve  Supply  of  the  Large 

Intestine 

The  blood  supply  of  the  large  intestine  is  derived  from  the 
three  colic  vessels,  the  left  colic  artery,  a  branch  of  the  inferior 
mesenteric  artery,  and  the  middle  and  superior  colic  arteries, 
branches  of  the  superior  mesenteric  artery. 

The  veins,  which  have  a  course  parallel  to  that  of  the  arteries, 
empty  into  the  superior  and  inferior  mesenteric  veins. 

According  to  Sappey,  the  lymphatics  of  the  intestinal  wall  are 
numerous  and  form  two  sets — a  deeper,  beneath  the  glands  of 
Lieberkühn,  and  a  more  superficial,  which  forms  a  network  ramify- 
ing in  all  directions  in  the  submucosa. 

The  7ierves  which  supply  the  caecum,  ascending  colon,  and  the 
right  half  of  the  transverse  colon  are  derived  from  the  superior 
mesenteric  plexus,  which  is  given  off  by  the  coeliac  plexus.  The 
left  half  of  the  transverse  colon,  the  descending  colon,  and  the  sig- 
moid flexure  receive  their  nerve  supply  from  the  inferior  mesenteric 
plexus,  which  in  its  turn  is  derived  from  the  plexus  of  the  abdomi- 
nal aorta. 

Histology  of  the   Large  Intestine 

Like  the  wall  of  the  stomach  and  small  intestines,  that  of  the 
large  intestine  is  composed  of  four  layers :  serous,  mucous,  sub- 
mucous, and  muscular. 

The  sercms  coat  has  already  been  considered  in  speaking  of  the 
separate  segments  of  the  intestine. 

The  muscular  coat  consists  of  an  external  longitudinal  and  an 
internal  circular  layer.  The  longitudinal  layer  is  not  found  through- 
out the  entire  gut,  but  appears  as  three  broad  longitudinal  bands, 
tcenia  {ligaTnenti)  coli,  which  are  each  10  millimetres  in  width  and  2 
to  3  millimetres  in  thickness,  and  are  all  visible  through  the  serosa. 
Beginning  at  the  attachment  of  the  appendix,  they  continue  as 
separate  bands  as  far  as  the  rectum,  where  they  unite  to  form  a 
continuous  muscular  layer. 

One  of  these  bands  is  seen  at  the  attachment  of  the  gastro-colic 
omentum  of  the  transverse  colon ;  at  its  mesenteric  border  is  a 
second,  while  the  third  band  is  free.  Hence  they  are  known  as  the 
tmnia  omentalis,  mesenterica  and  the  libera.  Between  them  there 
is  a  triple  row  of  alternately  protruding  and  receding  areas.  The 
protruding  parts  are  termed  the  haustra  coli  ;  the  depressions,  which 


IQ  DISEASES  OP  THE   INTESTINES 

are  parallel  to  each  otlier  and  perpendicular  to  the  plane  of  the  wall 
of  the  gut,  are  known  as  the  pockets.  Wherever  haustra  and  taenia 
cross,  we  find  projections  of  the  serous  coat,  rich  in  fat,  called  ap- 
pendices epiploiccB. 

The  circular  coat  extends  over  the  entire  colon ;  it  is  strongest 
between  the  haustra,  which  it  surrounds  by  folds  of  considerable 
thickness  {pliccB  sigmoide(M).  _ 

The  submucosa  is  entirely  like  that  of  the  small  intestines. 

The  mucous  membrane  diifers  from  that  of  the  small  intestines, 
above  all,  through  the  absence  of  Kerkring's  folds  and  of  villi.  It 
is  thicker  than  that  of  the  small  intestine.  The  muscularis  mucosa, 
a  thin  layer  of  crossed  muscular  fibres,  lies  beneath  the  mucosa. 
The  glands  of  Lieberkühn  lend  a  sievelike  appearance  to  the 
mucous  membrane  of  the  large  intestine.  These  glands  resemble 
the  glands  of  the  small  intestine,  but  are  longer  and  more  frequently 
branched  than  the  latter.  The  mucous  membrane  between  Lieber- 
kiihn's  glands  contains  cylindrical  epithelium,  goblet  cells,  and 
numerous  solitary  lymphatic  nodules. 

6.  The  Rectum 

We  include  in  the  term  rectum  the  lower  segment  of  the  large 
intestine  from  the  sigmoid  flexure  to  the  anus.  The  rectum  com- 
mences at  the  sacro-iliac  synchondrosis,  and  therefore  lies  entirely 
within  the  pelvis.  It  varies  in  length  from  18  to  22  centimetres 
(according  to  other  authorities,  25  to  33  centimetres).  Its  lumen  is 
narrower  than  that  of  the  sigmoid  flexure ;  immediately  above  its 
termination  there  is  a  normal  dilatation,  the  ampidla  recti,  which 
even  normally  varies  largely  in  size.  Contrary  to  its  name,  the 
rectum  is  not  straight,  but  presents  curves,  three  of  which  can  be 
distinguished.  Beginning  at  the  sacro-iliac  articulation,  it  at  first 
passes  slantingly  downward  and  to  the  right,  then  runs  forward  in 
front  of  the  lower  portion  of  the  sacrum  and  coccyx,  being  (in  men) 
behind  the  Ijladder,  the  seminal  vesicles,  and  the  prostate,  or  (in 
women)  behind  the  cervix  of  the  uterus  and  the  vagina.  Behind 
the  last-named  organs  (or  the  prostate)  the  rectum  again  curves 
downward  and  backward  and  terminates  at  the  anus. 

For  practical  purposes  we  distinguish  between  the  rectum  proper 
and  the  anal  portion — i.  e.,  the  part  surrounded  by  the  sphincter 
ani. 

The  upper  portion  only  of  the  rectum  is  covered  by  peritoneum, 
the  mesorectum,  a  direct  continuation  of  the  mesocolon  sigmoidea. 


PRELIMINARY  ANATOMICAL   AND   HISTOLOGICAL   REMARKS     17 

Like  the  sigmoid,  the  upper  portion  of  the  rectum  has  also  some 
range  of  motion.  Farther  down,  tlie  peritoneum  recedes  from  the 
rectum  and  is  reflected  on  to  the  bladder  in  the  male,  or  on  to  the 


Fig.  10. — Male  Pelvic  Organs,  viewed  from  the  Right  Side  (  x  »/g). 
(The  right  ilium  and  a  portion  of  the  ischium  and  the  pubic  bone,  together  with  their 
soft  parts,  have  been  removed.)  i,  auricular  surface  of  the  sacrum ;  ^,  tuberosity  of  the 
sacrum;  5,  ischium;  4,  pubic  bone:  5,  psoas  muscle;  6,  erector  spins ;  7,  glutei  muscles;  8, 
obturator  muscles ;  9,  external  sphincter  of  anus ;  10,  rectum  ;  11,  sigmoid  flexure ;  1£,  blad- 
der ;  13,  ureter ;  I4,  vas  deferens ;  15,  seminal  vesicles ;  16,  prostate ;  17,  penis ;  18,  prepuce ; 
19,  scrotum  ;  SO,  lateral  vesical  ligament ;  SI,  hypogastric  artery  ;  SS,  hypogastric  vein ;  23, 
external  iliac  artery;  S4,  abdominal  aorta.     (Rauber.) 

vaginal  vault  and  uterus  in  the  female.  Above  the  point  of  reflec- 
tion two  crescentic  folds,  inclosing  smooth  muscle  fibres,  pass  from 
the  sides  of  the  rectum  to  the  bladder  or  to  the  uterus  (the  folds  of 


IQ  DISEASES   OF   THE  INTESTINES 

Douo-las).  The  space  beneath  these  folds  is  known  as  the  j^ecto- 
vagi7ial,Sind  the  one  above  as  the  recto-vesical,  ßouch. 

The  relative  position  of  these  peritoneal  folds  is  not  constant, 
however,  but  varies  according  to  age  and  sex,  as  well  as  to  special 
conditions  of  the  neighboring  organs.  The  above  subdivision  is 
therefore  of  an  anatomical  rather  than  a  practical  value  (von  Es- 
march). 

The  muscular  coat  of  the  rectum  consists  of  an  inner  circu- 
lar and  an  outer  longitudinal  layer.  The  circular  layer,  which  is 
directly  continuous  with  that  of  the  colon,  constantly  increases  in 
thickness  toward  the  lower  end  of  the  gut,  finally  forming  a  ring 
1  or  2  centimetres  in  length,  the  internal  sphincter  of  the  anus. 
The  external,  the  longitudinal,  layer  is  continuous  with  the  three 
longitudinal  bands  of  the  colon.  In  the  rectum  it  forms  a  uniform 
layer,  interrupted  here  and  there  by  small  intervals.  The  fibres 
become  thinner  in  the  lower  part  of  the  rectum,  and  finally  merge 
with  those  of  the  external  sphincter. 

Contrasted  with  the  feeble  muscular  coat  of  the  upper  portion 
of  the  rectum,  the  anal  portion  contains  two  powerful  bands  of  cir- 
cular fibres  which  secure  closure  of  the  anus.  They  are  the  exter- 
nal and  internal  sphincters  {sphincter  ani  externus  et  internus). 

The  external  sphincter,  whose  action  is  voluntary,  arises  by  a 
tendinous  origin  from  the  apex  of  the  coccyx,  and  separates  into 
two  divisions  which  surround  the  anal  orifice.  In  front  of  the  anus 
it  is  connected,  in  the  male,  with  the  musculus  bulbo-cavernosus,  or 
transversus  perinei,  and  in  the  female  with  the  constrictor  cunni. 

The  internal  sphincter  of  the  anus,  a  ring  or  girdle  of  smooth 
muscle  fibres,  is  the  direct  prolongation  of  the  circular  layer  of  the 
rectum  ;  these  fibres  gradually  increase  in  strength  as  they  approach 
the  anus.  Connected  with  the  internal  sphincter  are  two  muscular 
fasciculi,  4  millimetres  in  width,  which  spring  from  the  anterior 
surface  of  the  coccyx  and  sui'round  the  lower  end  of  the  rectum  (the 
musculi  recti-coccygei). 

A  short  distance  below  the  middle  of  the  rectum  fabout  8  centimetres  above 
the  anal  orificej  we  sometimes  find  a  prominent  collection  of  circular  fibres,  to 
which  the  name  ^^ sphincter  ani  tertius''''  has  been  given  (Hyrtlj.  This  "sphinc- 
ter," however,  is  nothing  more  than  the  transverse  rectal  fold  increased  by  some 
circular  fibres. 

The  mucous  membrane  of  the  rectum  is  thicker,  redder,  and 
more  succulent  than  that  of  the  colon.  It  presents  many  folds, 
varying  in  size  and  directions,  and  disappearing  when  the  organ  is 


PRELIMINARY   ANATOMICAL   AND   HISTOLOGICAL   REMARKS     19 

strongly  distended.  They  are  most  distinct  when  the  rectum  is 
empty.  One  deep,  transverse  fold  alone  does  not  disappear  even 
with  the  greatest  possible  distention  of  the  rectum.  This  fold — the 
ßyica  transverscdis  recti — is  about  6  to  8  centimetres  above  the 
anus,  and  can  be  distinctly  seen  through  a  speculum.  It  is  a  sickle- 
shaped  reduplication  of  the  mucous  membrane,  and  does  not  include 
the  entire  circumference  of  the  rectum,  l^ear  the  anal  opening 
the  folds  are  usually  longitudinal,  and  have  received  the  name  of 
rectal  or  columns  of  Morgagni.  The  pockets  between  the  folds  are 
known  as  sinuses  of  Morgagni ;  they  are  favourite  lodging  places 
for  intestinal  parasites  and  for  swallowed  pointed  foreign  bodies. 
The  mucous  membrane  covering  these  folds  and  pockets  differs 
from  that  of  the  rest  of  the  rectum  by  the  absence  of  glands  and  by 
the  presence  of  moderate-sized  papillae,  partly  agminated.  The 
epithelium  is  stratified,  and  consists  of  large  pavement  cells.  Thus, 
the  lower  portion  of  the  rectum  forms  a  transition  from  mucous 
membrane  of  the  intestinal  canal  to  skin  (Henle).  The  mucous 
membrane  of  the  upper  portion  of  the  rectum  differs  in  no  respect 
from  that  of  the  remainder  of  the  large  intestine. 

The  rectum  receives  its  blood  from  five  arteries,  branches  of 
three  arterial  trunks.  The  largest  of  these  five,  the  superior  h?em- 
orrhoidal  artery,  is  given  off  by  the  inferior  mesenteric  ;  the  middle 
hsemorrhoidal  arteries,  two  in  number,  come  either  from  the  hypo- 
gastric or  from  the  common  pudendal ;  the  two  smallest  vessels,  the 
inferior  hsemorrhoidal  arteries,  come  from  the  common  pudendal. 

The  blood  is  carried  away  from  the  rectum  for  the  most  part 
by  the  portal  system  through  the  superior  hsemorrhoidal  vein,  and 
the  remainder  by  the  middle  and  external  hsemorrhoidal  veins, 
which  empty  into  the  infei'ior  vena  cava. 

The  lymphatics  form  an  extensive  network  with  wide  meshes, 
which  sends  some  branches  to  the  retrorectal  glands  and  others  to 
the  left  lumbar  plexus. 

The  nei'ves  are  derived  mainly  from  the  sympathetic.  They 
come  from  the  inferior  mesenteric  plexus,  the  sacral  plexus  (inferior 
and  middle  hsemorrhoidal  nerves),  and  from  the  superior  hypogastric 
plexus. 


20  DISEASES  OF   THE   INTESTINES 


APPENDIX 

Displacements  of  the  Various  Segments  of  the   Intestines 

As  a  consequence  of  congenital  or  acquired  anomalies,  the  va- 
rious segments  of  the  intestines  maj  undergo  alteration  in  posi- 
tion. These  displacements  are  verj  important  for  the  diagnos- 
tician, and  in  order  to  prevent  serious  error  it  is  necessary  that  he 
be  acquainted  with  or  at  least  consider  them.  The  portions  most 
frequently  affected  are  the  duodenum  and  the  entire  large  intes- 
tine, exclusive  of  the  rectum ;  much  less  frequently,  and  usually  as 
a  consequence  of  the  above  anomalies,  the  remainder  of  the  small 
intestine. 

The  superior  horizontal  portion  of  the  duodenum  is  so  closely 
connected  with  the  stomach  that  it  would  naturally  be  affected  by 
alterations  in  position  of  that  organ.*  Should  the  stomach  be 
pushed  toward  the  left  side,  the  superior  horizontal  portion  of  the 
duodenum  would  be  on  a  line  with  the  pylorus.  If  the  pylorus  be 
dragged  to  the  left  of  the  median  line  of  the  body,  the  first  portion 
of  the  duodenum  will  then  lie  upon  the  vertebral  column.  Should 
the  pylorus  be  within  the  median  line  or  to  the  right  thereof,  the 
same  portion  of  the  duodenum  will  curve  around  the  vertebral  col- 
umn (Hertz).  The  gut  thus  becomes  more  superficial,  and  the 
superior  flexure  of  the  duodenum  is  bent  almost  at  a  right  angle. 
"Where  there  is  a  fish-hook-shaped  ptosis  of  the  stomach,  the  first 
portion  of  the  duodenum  will  also  be  drawn  downward,  and  will 
assume  an  almost  vertical  position.  A  sharp  bend  is  thus  given  to 
the  flexure,  and  it  may  be  so  pronounced  as  to  even  cause  a  partial 
obstruction  of  the  contents.  Again,  where  the  stomach  in  toto  is 
sunken,  it  will  drag  the  first  portion  of  the  duodenum,  or  even  the 
entire  duodenum,  down  with  it.  Under  other  conditions  the  duo- 
denum can  preserve  its  normal  position. 

The  descending  portion  of  the  duodenum  is  less  freely  movable, 
because  of  its  close  connection  with  the  pancreas.  Despite  this, 
both  organs  may  be  simultaneously  displaced.  Bi'aune  observed  a 
case  in  which  this  portion  of  the  duodenum  was  dislocated  to  the 
left.  Displacement  of  other  organs,  especially  of  the  stomach,  the 
liver,  transverse  colon,  etc.,  naturally  causes  displacement  of  the 

*  See   Hertz.     Abnormitäten  in   der   Lage  und   Form  der   Bauchorgane,  etc., 
Berlin,  1894,  S.  33. 


PRELIMINARY  ANATOMICAL  AND  HISTOLOGICAL  REMARKS    21 

duodenum  as  well.  Nevertheless,  the  tendency  of  the  descending 
portion  to  become  dislocated  is  limited. 

The  inferior  horizontal  portion  is  subject  to  slight  alterations  in 
position  alone,  and  these  are  brought  about  by  the  same  conditions 
as  those  of  the  remainder  of  the  duodenum.  We  wish  here  to  call 
attention  to  the  large  number  of  adhesions  which  occur  in  the  region 
of  the  gall  bladder  and  the  duodenum,  and  which  may  create  great 
difficulties  in  diagnosis  as  well  as  in  treatment. 

Alterations  in  position  of  the  colon  are  most  common.  Cursch- 
mann  ^  has  recently  called  attention  to  their  clinical  importance. 
The  following  statements  are  taken  largely  from  Curschmann's 
excellent  treatise. 

1.  The  C^cum  and  the  Ascending  Colon 

The  caecum  may  be  abnormally  long,  and  thus  give  rise  to  vol- 
vuli,  kinking,  and  flexures.  In  such  cases  the  fundus  of  the  csecum 
is  directed  toward  the  diaphragm,  and  covers  a  part  of  the  ascend- 
ing colon.  Thus  we  may  at  times  have  a  total  occlusion  of  the 
gut.  It  should  be  remembered  that  such  a  dislocated  caecum,  to- 
gether with  the  appendix,  may  be  the  seat  of  a  perityphlitis. 

In  those  very  rare  cases  in  which  the  ascending  colon  is  con- 
genitally  entirely  absent,  the  caecum  with  its  appendix  lies  very 
close  to  the  edge  of  the  liver,  or  behind  that  organ.  Perityphlitis 
has  been  observed  under  such  conditions,  but  the  clinical  diagnosis 
is  very  difficult,  if  not  impossible. 

2.  The  Teansyeese  Colon  and  the  Flexuees 

It  is  a  well-known  fact  that  the  transverse  colon  [especially  in 
the  female]  is  subject  to  the  greatest  variations  in  position.  This  is 
probably  due  to  the  habit  of  lacing,  through  which  one  portion  of 
the  abdominal  contents  is  forced  upward  and  the  other  downward. 
When  its  mesentery  is  excessive  in  length,  the  transverse  colon  may 
be  dislocated  upward  and  lie  in  the  epigastrium  in  front  of  the 
liver,  or  in  the  left  hypochondrium  in  front  of  the  stomach  (Hertz). 
In  other  cases,  the  transverse  colon  may  be  entirely  concealed  by 
coils  of  small  intestine  ;  we  then  find  it  low  down  in  the  posterior 
portion  of  the  abdomen  (Hertz). 

Absence  or  shortening  of  the  flexures  may  give  rise  to  condi- 
tions of  special  interest.  For  example,  the  colon  may  pass  from 
the  right  side  upward  and  toward  the  median  line ;  thence  trans- 
versely for  a  short  distance ;  then,  abruptly  bending  to  the  left,  con- 
3 


22  DISEASES  OP  THE  INTESTINES 

tinue  downward  as  the  descending  colon.  Again,  in  a  verj  long 
colon,  both  flexures  may  be  shortened  or  absent.  The  transverse 
colon  in  such  cases  forms  a  large  loop,  whose  segments  lie  close  to 
each  other  and  in  dii*ect  contact  with  the  liver,  and  may  cover  the 
entire  anterior  surface  of  that  organ.  Here  we  would  get  apparent 
diminution  in  liver  dulness  in  front,  but  percussion  of  the  lateral 
and  posterior  surfaces  should  save  us  from  mistakes. 

Marked  increase  in  length  of  the  large  intestine  may  give  rise 
to  the  coiling  together  of  the  intestines,  or  even  to  the  formation 
of  a  volvulus. 

3.  The  DescendijStg  Colon  and  the  Sigmoid  Flexure 

The  sigmoid  flexure  is  the  most  movable  segment  of  the  large 
intestine,  because  its  length  is  subject  to  the  greatest  variations. 
Its  displacements,  as  well  as  those  of  the  descending  colon,  have 
been  noted  by  the  older  anatomists.  Recently  Schieiferdecker^ 
and  von  Samson^  have  made  a  close  study  of  the  subject. 

Schiefferdecker  distinguishes  the  following  alterations  in  position  of  the 
descending  colon : 

I.  The  end  of  the  descending  colon  lies  to  the  side  of  the  sigmoid  flexure. 

(a)  The  flexure  projects  into  the  small  pelvis,  and  the  small  intestines  lie  in 
front  and  above  it. 

(b)  The  flexure  lies  upon  the  posterior  abdominal  wall,  and  is  directed  up- 
ward ;  a,  it  lies  within  the  left  half  of  the  body ;  ß,  it  extends  to  the  right  iliac 
fossa.  Between  these  extreme  left  and  right  positions  the  greatest  variations 
occur. 

(c)  Other  portions  of  the  intestines  separate  the  sigmoid  flexure  from  the 
posterior  abdominal  wall,  with  the  result  that  a  greater  or  lesser  portion  of  that 
gut  lies  directly  behind  the  anterior  abdominal  wall.  These  variations  can 
only  occur  with  a  free  mesosigmoideum,  and  the  higher  the  lateral  point  of 
fixation  of  the  sigmoideum,  the  greater  will  be  the  predisposition  to  these  dis- 
placements and  their  extent  upward.  The  apex  of  the  sigmoid  flexure  may 
move  from  the  extreme  left  side  of  the  body  to  the  extreme  right. 

II.  The  termination  of  the  descending  colon  lies  to  the  median  side  of  the 
sigmoid  flexure.     This  is  extremely  rare. 

Curschmann,  who  has  given  special  attention  to  the  clinical  im- 
portance of  the  anomalies  of  the  sigmoid  flexure,  lays  particular 
stress  upon  the  striking  differences  in  its  length  (60  to  80,  or  even 
100  centimetres).  Sometimes  there  are  two  coils  instead  of  one. 
A  more  frequent  anomaly  is  the  formation  of  an  abnormal  loop  be- 
tween the  lower  end  of  the  sigmoid  and  the  beginning  of  the  rectum. 
In  such  cases  we  almost  always  find  the  lower  end  of  the  colon  far 


PRELIMINARY  ANATOMICAL  AND   HISTOLOGICAL  REMARKS    23 

down  in  tlie  pelvis  and  over  to  the  right  side.  Under  such  circum- 
stances, the  commencement  and  termination  of  the  large  intestine 
lie  side  by  side.  It  is  very  apparent  how  gross  errors  in  diagnosis 
may  occur.  This  has  been  very  aptly  illustrated  in  one  of  Cursch- 
mann's  cases.  The  position  of  the  coils  of  the  sigmoid  may  also  be 
greatly  altered.  ÜSTormally,  they  are  in  the  centre  of  the  abdomen, 
their  long  axis  being  parallel  with  the  linea  alba.  The  upper  bor- 
der is  in  contact  with  the  transverse  colon.  With  increase  of 
length  the  coils  may  even  reach  the  vault  of  the  diaphragm,  and 
completely  cover  the  stomach  and  liver.  This  abnormality  in  posi- 
tion may  make  it  difficult  to  determine  the  limits  of  the  liver  and 
stomach.  It  appears  that  almost  invariably  the  base  of  the  coils  is 
covered  by  small  intestine.  If  volvulus  should  occur  in  these 
cases,  we  should  then  find  tympanitic  intestinal  coils  at  all  points, 
excepting  the  one  at  which  the  volvulus  is  situated — i.  e.,  the  region 
of  the  sigmoid  flexure. 

LITERATURE 

1.  Curschmann.     Deutsch.  Archiv  für  klin.  Medicin,  Bd.  liii,  H.  1  u.  3. 

2.  Schiefferdecker.     Archiv  für  Anatomie  u.  Physiologie,  1886  u.  1887. 

3.  V.  Samson.     Zur  Kenntniss   der  Flexura  sigmoidea  coli.     Inaug. -Dissert., 

Dorpat,  1890.     (Complete  literature.) 


CHAPTER  II 

PBELIMINABY  PHTSIOLOGICAL  AND  PEY8I0L0GIC0- 
CHEMIGAL  BEMARE8 

The  digestive  process  in  the  intestines  is  far  more  complicated 
than  in  the  stomach.  In  the  latter  the  digestive  act  is  but  a  pre- 
paratory one,  affecting  only  the  proteid  bodies  (and  gelatinoid  sub- 
stances) and  the  starches.  Absorption,  as  we  now  know,  takes 
place  but  to  a  limited  extent  (v.  Mering,  Brandl,  Moritz,  Hirsch, 
and  others).  The  digestive  task  of  the  intestines  consists  princi- 
pally in  converting  all  food  stuffs,  brought  to  it  from  the  stomach, 
into  a  form  suitable  for  assimilation ;  in  absorbing  the  useful  por- 
tions, and  gathering  together  in  a  solid  form  and  excreting  from 
the  body  all  waste  material.  The  intestines,  however,  have  another 
function,  heretofore  but  little  appreciated  by  physiologists  and  clini- 
cians— i.  e.,  the  removal  in  the  form  of  flatus  of  noxious  gases  devel- 
oped in  the  intestinal  canal.  This  might  be  termed  intestinal  ven- 
tilation. 

All  the  functions  of  the  intestines  harmonize  like  the  component 
parts  of  a  score  ;  interference  with  one  deranges  all.  Strictly  speak- 
ing, then,  these  functions  should  not  be  considered  separately.  If, 
nevertheless,  we  do  so  in  the  following,  it  is  because  the  entire  pro- 
cess of  digestion — the  influence  exerted  by  a  single  function  upon 
the  whole,  and  vice  'versa — is  not  well  enough  understood  either  in 
man  or  in  the  lower  animals. 

In  the  following  we  shall  first  treat  separately  of  intestinal  secre- 
tion, absorption,  and  motility,  and  then  of  the  entire  course  of  intes- 
tinal digestion.  As  by-products  of  intestinal  activity,  we  have  cer- 
tain fermentation  substances,  some  useful,  others  harmful.  They 
also  will  be  considered  in  the  section  on  intestinal  digestion  in  its 
entirety  (page  43). 

THE  SECRETING   FUNCTION  OF  THE  INTESTINES 

The  secretion  furnished  by  the  intestines  themselves  plays  but 
an  insignificant  part  in  the  digestive  process.     The  main  work  is 
24 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL   REMARKS     25 

accomplished  bj  the  secretions  from  the  two  glands  emptying  into 
the  small  intestine,  viz.,  the  liver  and  the  pancreas. 

1.  The  Intestinal  Juice 

This  is  a  mixture  of  secretions  from  Brunner's  and  from  Lieber- 
kühn's  glands.  Grützner ^  ascribes  the  faculty  of  secreting  pepsin 
to  Brunner's  glands ;  this  would  give  them  functions  analogous  to 
those  of  the  pyloric  glands.  They  certainly  do  not  secrete  any 
diastatic  ferment.  Other  investigators  regard  Brunner's  simply  as 
mucous  or  salivary  glands. 

Our  information  regarding  the  secretion  of  Lieberkühn's  glands 
is  more  definite,  for  this  has  been  studied  in  animals  by  the  aid  of 
the  Thiry  or  Yella  fistula,  and  also  in  individuals  with  fsecal  fistulae 
(Dumont,  Turby  and  Manning).  Observations  thus  made  showed 
the  secretion  to  be  pale  yellow  in  colour,  highly  albuminous  and  muci- 
form,  and  containing  about  0.5  per  cent,  of  sodium  chlorid  and  a 
like  amount  of  sodium  carbonate.  Hoppe-Seyler^  lays  special  value 
upon  this  mucosity,  since  mucin  forms  a  protective  coating  for  the 
intestinal  epithelium,  and  makes  possible  as  well  as  facilitates  the 
passage  of  the  solid  masses  within  the  intestines. 

Another  very  important  factor  is  the  presence  of  the  carbonate 
of  soda.  This  affects  the  rapid  neutralization  of  the  acid  stomach 
chyme.  Bunge,^  in  fact,  ascribes  the  importance  of  the  intestinal 
secretion  mainly  to  its  carbonate  of  soda.* 

In  dogs,  the  solids  of  the  intestinal  juice  equal  12.2  to  21.1 
grams  per  1,000 ;  in  sheep,  46  to  47  grams.  According  to  Thiry, 
the  specific  gravity  of  the  secretion  varies  in  dogs  from  lOlO  to 
1017. 

It  is  generally  conceded  that  the  fermentative  action  of  the  in- 
testinal juice  is  very  slight.  It  has  been  shown  that  starch  after  a 
long  time  is  converted  into  glucose,  and  cane  sugar  is  inverted 
through  the  action  of  the  intestinal  secretion  (Demant  *,  Brown  and 
Heron  %  K.  B.  Lehmann  ^,  Frick,  Turby  and  Manning ',  and  Miura  ^). 
Similarly  F.  Röhmann  and  Lappe  ^  have  found  that  an  extract  of 
mucous  membrane  from  the  small  intestine  of  the  calf  or  dog  can 
convert  milk  sugar  into  glucose.  The  secretion  from  Lieberkühn's 
glands  has  no  action  whatever  upon  albuminoid  bodies  and  fats 

*  In  diseased  conditions,  marked  odourless  eructations  may  occur  some  time  after 
eating.  It  appears  very  probable  to  me  that  this  results  from  decomposition  of  the 
hydrochloric  acid  of  the  stomach  by  the  alkaline  intestinal  secretion. 


26  DISEASES  OF  THE  INTESTINES 

(Frick  ^%  Ellenberger  and  Hofmeister  ^\  K.  B.  Lehmann  ^,  Wenz  ^^, 
and  others).  The  secretion  from  Lieberkiihn's  glands  in  the  large 
intestine  appears  to  be  mostly  mucous. 

2.  The  Panceeatic  Juice 

The  action  of  the  pancreatic  secretion  has  been  studied  princi- 
pally upon  animals  in  whom  fistulse  have  been  made.  A  few 
observations  have  been  made  with  the  secretion  from  fistulse  fol- 
lowing the  extirpation  of  pancreatic  tumours,  particularly  cysts. 
I  have  myself  made  a  few  such  observations.  The  credit  for 
most  of  our  knowledge  of  the  function  of  the  pancreas  is  due 
to  CI.  Bernard,  C.  Ludwig,  Bidder  and  Schmidt,  Heidenhain  and 
Bernstein.  The  fundamental  studies  of  v.  Mering  and  Minkowski 
first  brought  out  the  importance  of  the  pancreas  in  diabetes. 

In  experiments  upon  animals  two  varieties  of  fistulae,  the  temporary  and 
the  permanent,  are  employed.  If  a  fistula  be  made  in  a  dog  after  a  hearty 
meal,  the  secretion  which  flows  will  be  profuse,  viscid,  and  very  active.  Activ- 
ity ceases,  however,  after  a  few  days — sometimes  after  a  few  hours — and  it  is 
succeeded  by  a  thin,  watery,  inert  secretion,  very  poor  in  albuminoids,  and 
resulting  very  probably  from  inflammatory  changes.  In  a  few  cases  it  has 
been  possible  to  obtain  an  active  secretion  from  a  permanent  fistula.  It  is 
therefore  easily  understood  that  analyses  of  the  secretion  vary  very  much. 

The  normal  secretion  of  the  pancreas  is  a  clear,  colourless,  and 
odourless,  viscid  fiiiid,  of  a  strongly  alkaline  reaction.  The  alka- 
linity is  due  to  sodium  carbonate  which  is  present  in  from  0.2 
to  0.4  per  cent.  The  secretion  is  highly  albuminous  and  coagu- 
lates strongly  upon  boihng.  In  addition  to  the  above,  it  contains 
leucin,  fats,  fatty  soaps,  and  the  following  mineral  ingredients : 
Alkaline  chlorids  and  carbonates,  phosphoric  acid,  and  some  cal- 
cium, magnesium,  and  iron. 

In  the  secretion  from  a  temporary  fistula  of  a  dog,  C.  Schmidt  ^* 
once  found  9.92  per  cent  of  solids,  and  at  another  time  11.56  per 
cent;  while  Zawadsky^",  in  examination  of  pancreas  fistula  of  a 
man,  found  13.25  per  cent  of  solids,  of  which  9.2  per  cent  were 
Proteids  and  0.34:  per  cent  mineral  substances.  Herter^^  found 
24.1  per  cent  solids  in  the  secretion  of  a  man;  this  secretion, 
though  very  active,  seems  to  have  been  pathological  in  other 
respects.  From  the  above  analyses,  we  may  regard  10  per  cent  as 
the  average  amount  of  solid  matter. 

The  most  important  pancreatic  ferments  are  the  proteolytic,  the 
amylolytio,  and  the  fat-splitting. 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL  REMARKS     27 

(a)  At  the  proper  temperature  the  proteolytiG  f'enne7it,  trypsin 
(Kühne),  is  capable  of  converting  proteids  in  a  A'ery  short  time  into 
albumoses  and  peptones.  This  ferment  does  not  exist  preformed 
within  the  gland,  but  is  there  instead  as  trypsinogen  (Heidenhain 
and  Podolinski  ^^),  Trypsinogen  is  changed  into  trypsin  through 
bacterial  influences,  contact  with  air  or  water,  or  with  dilute  acids 
(e.  g.,  1  per  cent  acetic  acid).  Trypsin  is  most  active  in  a  0.2-  or 
0.4-per-cent  solution  and  at  40°  C.  Small  amounts  even  of  free 
mineral  acids  retard  its  action,  but  organic  acids  must  be  present  in 
stronger  concentration.  The  kind  of  albuminous  matter  is  not 
without  influence.  Thus,  as  in  gastric  juice,  fibrin  is  digested 
much  quicker  than  is  coagulated  egg  albumen. 

The  initial  stage  of  proteid  digestion  with  trypsin  differs  very 
much  from  that  with  the  gastric  juice.  Whereas  in  the  latter 
there  is  a  preliminary  swelling  of  the  albuminoid  substance  fol- 
lowed by  gradual  solution,  in  trypsin  digestion  there  is  a  breaking 
up,  or,  more  properly  speaking,  a  melting  away. 

As  in  the  stomach,  so,  too,  in  trypsin  digestion  the  metamor- 
phosis of  the  albuminoids  is  not  a .  sudden  but  a  gradual  one. 
According  to  Kühne,  who  has  studied  the  proteolysis  of  trypsin 
digestion  more  carefully  than  any  one  else,  the  albuminoids  are 
first  converted  into  deutero  -  albumoses,  but  after  a  very  short 
time  peptones  are  also  present.  One  portion  of  these  peptones — 
Kühne's  antipeptones — remains  unchanged  throughout  the  entire 
digestion,  even  though  this  may  continue  for  several  days,  while 
another  portion — Kühne's  hemipeptones — yields  products  of  decom- 
position, the  most  important  of  which  are  the  crystalline  amido- 
acids — leucin,  tyrosin,  and  aspartic  acids.  These  latter  products 
have  been  well  known  for  a  long  time ;  of  late,  E.  Drechsel  and 
Iledin"  have  succeeded  in  isolating  two  additional  products  of 
trypsin  digestion,  lysin  and  lysatinin.  Finally,  a  chromogen,  tryp- 
tophan, is  regularly  formed  during  tryptic  action  upon  albumi- 
noids^^. With  bromin  or  chlorin  water,  or  with  chlorate  of  potash 
solution,  tryptophan  yields  a  violet  colouring  matter,  readily  absorbed 
by  amylic  alcohol. 

Trypsin  also  acts  upon  the  gelatins,  causing  them  to  lose  their 
gelatinous  qualities  and  to  be  converted  into  gelatin  peptones. 
Kühne's  and  Roberts's  ^^  investigations  with  the  trypsin  of  pigs' 
pancreas  have  shown  that  this  ferment  curdles  milk.  My  own 
investigations^  have  proved  that  milk  is  not  curdled  by  the  biliary 
juice  contained  in  the  duodenum  (a  mixture  of  bile,  pancreatic 


28  DISEASES  OP  THE  INTESTINES 

juice,  and  tlie  secretions  of  Brunner's  and  Lieberkühn's  glands), 
but  that  it  is  immediately  peptonized.  If  the  gelatin-yielding  sub- 
stance of  connective  tissue  is  previously  svrelled  by  the  action  of 
acids,  or  shrunken  through  the  agency  of  heat,  it  will  be  dissolved. 
Elastic  membranes,  as  well  as  the  membranes  of  fat  globules,  are 
immediately  dissolved.  Chitin  and  keratin  apparently  are  not 
dissolved  by  trypsin. 

(h)  Pancreatic  Diastase. — This  ferment  has  the  property  of 
converting  starch  and  glycogen  into  sugar,  the  end  products  being 
mostly  maltose,  together  with  small  quantities  of  dextrose  (Muscu- 
lus and  Gruber  ^^  and  v.  Mering^).  This  conversion  is  a  hydration 
process,  and  the  intermediate  products  are  the  same  as  those  occur- 
ring in  the  diastatic  action  of  ptyalin,  with  which  ferment  pancreas 
diastase  is  in  all  probability  identical.  Taken  in  their  order  of 
occurrence  these  intermediate  products  are :  first,  soluble  starch, 
which  still  gives  a  blue  colour  with  Lugol's  solution  of  iodin ;  next, 
erythrodextrin,  which  gives  a  violet  colour ;  and,  finally,  one  or 
more  of  the  achroodextrins,  which  remain  nncoloured  upon  addition 
of  Lugol's  solution. 

In  addition  to  diastase,  pancreatic  juice  also  contains  invertin, 
although  in  much  smaller  quantities  than  does  the  intestinal  secre- 
tion. It  is  assumed  that  this  ferment  gradually  completely  con- 
verts maltose  into  dextrose  (glucose).  In  like  manner  cane  sugar 
and  milk  sugar  are  also  converted  into  glucose  by  invertin.  Glyco- 
gen is  first  converted  into  a  maltoselike  sugar,  and  then  gradually 
also  changed  into  glucose. 

(c)  The  Fat-splitting  Ferment  {Steapsin). — This  ferment  splits 
up  fats  into  fatty  acids  and  glycerin.  In  the  presence  of  alkalies 
these  fatty  acids  combine  to  form  soaps  ;  furthermore,  they  aid 
very  much  in  the  emulsification  of  fats.  We  shall  return  to  this 
when  we  come  to  speak  of  bile.  Steapsin  has  not  yet  been  iso- 
lated, and  the  attempt  has  therefore  been  made  to  refer  the  spht- 
ting  up  of  fats  in  the  intestines  to  the  action  of  bacteria.  The 
researches  of  Neneki  ^^  have,  however,  shown  the  positive  existence 
of  a  fat-splitting  ferment  in  pancreatic  juice.  In  my  own  investi- 
gations ^  with  the  small  intestinal  juices  of  man  I  have  observed 
marked  fermentative  dissolution  of  fat. 

According  to  ISTencki  and  Baas^^,  pancreatiq  ferment  decom- 
poses other  esters  besides  the  neutral  fats.  We  shall  speak  of  the 
part  played  by  the  pancreatic  juice  during  digestion  when  discuss- 
ing intestinal  digestion  in  its  entirety. 


PHYSIOLOGICAL  AND  PHYSIOLOGICO-CHEMICAL  REMARKS     29 

3.  The  Bile 

The  importance  of  the  bile  in  digestion  was  formerly  very 
much  overestimated.  At  the  present  day  bile  may  be  looked  upon 
as  possessing  more  of  an  excretory  than  a  secretory  importance, 
since  it  has  to  render  innocuous  the  products  of  body  metabolism 
stored  up  in  the  liver  and  safely  conduct  them  from  the  body  by 
way  of  the  intestines.  It  would  be  going  too  far,  however,  to 
assign  but  this  one  function  to  the  bile.  Without  doubt  it  has  an 
important  part  in  intestinal  digestion,  especially  in  regard  to  the 
fats.     This  will  be  referred  to  again  later. 

The  composition  of  bile  varies  with  different  animals  ;  that  of 
the  dead  body  is  different  from  that  of  the  living,  and  that  flowing 
from  the  biliary  passages  is  not  the  same  as  that  contained  within 
the  gall  bladder. 

Human  bile,  such  as  is  obtained  immediately  after  death  from 
executed  persons,  is  usually  of  a  golden-yellow  colour  with  a  shade 
of  brown.  Greenish-coloured  bile  has  also  been  seen,  especially 
during  operations.  Bile  such  as  I  have  seen  regurgitated  into  the 
stomach  in  numerous  cases  of  deeply  situated  duodenal  stenoses  was 
almost  always  green  ;  in  a  very  few  eases  where  there  was  a  normal 
condition  of  the  duodenum,  I  saw  bile  of  a  golden-yellow  colour. 
The  taste  of  bile  varies  in  different  animals  ;  that  of  man  and  of 
cattle  is  bitter  and  has  a  sweetish  after  taste,  while  that  of  the  rab- 
bit and  the  pig  has  a  purely  bitter  taste.  The  specific  gravity  of 
that  in  the  gall  bladder  varies  from  1001  to  1004.  The  reaction  is 
faintly  alkaline,  due  to  the  presence  of  the  carbonate  of  soda  (.02 
per  cent)  and  of  alkaline  sodium  phosphate.  The  amount  of  solids 
in  bile  obtained  from  fistulas  varies  so  largely  that  figures  are  value- 
less. This  holds  true,  too,  for  the  total  quantity  in  twenty -four 
hours  of  bile  from  fistulse,  for  an  appreciable  but  immeasurable 
portion  must  flow  into  the  small  intestine  itself.  Besides,  as  Stadel- 
mann  has  correctly  shown,  marked  variations  in  the  biliary  secre- 
tion may  occur  under  normal  conditions.  Bile  contains  very  much 
mucin  as  well  as  mucoid  nucleo-albumin. 

The  most  important  constituents  of  bile  are  the  two  biliary  acids 
and  their  salts — the  glycocholate  of  soda  and  the  taurocholate  of 
soda — Cholesterin,  and  a  number  of  biliary  colouring  matters.  In 
addition  there  are  small  quantities  of  lecithin,  neutral  fats,  soaps, 
urea,  and  mineral  salts. 

As  regards  the  two  biliary  acids,  it  should  be  stated  that  glyco- 


30  DISEASES  OF  THE  INTESTINES 

cholic  acid  (C26H43]Sr06),  wliicli  is  combined  witli  sodium  and  traces 
of  potassium,  is  more  abundant  in  man  ;  while  taurocholic  acid 
(C26H4ö^S07)  is  found  in  Carnivora  and  in  goats  and  slieep.  As 
can  be  seen  from  the  formula,  taurocholic  acid  contains  both  nitro- 
gen and  sulphur,  whereas  neither  of  these  substances  is  present  in 
gljcocholic  acid.  Both  acids  have  a  bitter  taste  and  are  dextro- 
gyrous ;  they  are  decomposed  upon  boiling  with  caustic  potash, 
glycocholic  acid  splitting  up  into  glycin  and  cholic  acid,  and  tauro- 
cholic acid  into  taurin  and  cholic  acid. 

The  biliary  colouring  matters  met  with  under  normal  conditions 
are  bilirubin  (reddish  yellow)  and  biliverdin  (green),  and  one  col- 
ouring substance  closely  related  to  hydrobilirubin  (urobilin). 

Biliruhin  (identical  with  heematoidin)  is  found  in  the  golden- 
yellow  bile  of  man,  and  is  present  to  a  marked  degree  in  biliary 
concretions  as  bilirubin-calcium.  It  is  insoluble  in  water,  sparingly 
soluble  in  ether,  a  little  more  so  in  alcohol,  and  readily  in  chloro- 
form, especially  if  warmed.  Upon  evaporation  it  may  be  obtained 
partially  in  crystalline  form,  partially  as  an  amorphous  substance. 
Solutions  of  bilirubin  in  chloroform  yield  reddish-yellow  rhombic 
scales  which  are  exactly  like  h^matoidin.  For  other  properties  of 
bilirubin,  as  well  as  for  its  chemical  reactions,  we  refer  the  reader 
to  works  on  chemical  physiology. 

Biliverdin  results  from  oxidation  of  bilirubin,  and  is  met  with 
in  the  bile  of  man,  of  the  lower  animals,  and  also  in  the  urine  of 
jaundice,  and  to  a  less  extent,  too,  in  gallstones.  It  is  an  amor- 
phous substance  readily  soluble  in  alcohol,  sparingly  in  ether,  and 
insoluble  in  chloroform,  thus  differing  widely  from  bilirubin. 

Hydrobilirubin  results  from  the  reduction  of  bilirubin,  and  is 
constantly  present  as  colouring  matter  in  normal  faeces.  It  is  in  all 
probability  identical  with  urobilin  and  the  so-called  stercobilin. 

Cholesterin  is  held  in  solution  by  the  bile  salts.  .  It  crystallizes 
in  colourless  rhombic  plates,  is  insoluble  in  water,  but  soluble  in 
hot  alcohol,  in  ether  and  chloroform. 

It  is  claimed  that  in  addition  to  the  above-described  constituents, 
there  is  also  a  diastatic  ferment  present  in  bile  ;  but  very  probably 
it  is  the  diastase  of  the  salivary  and  intestinal  secretions. 

Importance  of  Bile  in  Intestinal  Digestion. — Apparently  the 
principal  function  of  the  bile  is  to  promote  the  absorption  of  fat. 
This  is  readily  seen  from  the  fact  that  dogs  with  biliary  fistulse 
absorb  far  less  fat  than  do  normal  animals.  Whereas  a  normal 
dog,  according  to  Yoit^",  given  150  to  250  grams  of  fat  will  absorb 


PHYSIOLOGICAL  AND  PHYSIOLOGICO-CHEMICAL  REMARKS     31 

99  per  cent  of  it,  one  witli  a  biliary  fistula  given  100  to  150  grams 
can  absorb  but  40  per  cent,  the  remaining  60  per  cent  passing  off 
with  the  faeces.  Röhmann  ^"^  arrived  at  similar  conclusions.  On  the 
other  hand,  it  may  be  stated  as  an  actual  fact  that  no  disturbance  of 
digestion  occurs  when  the  bile  is  conducted  externally,  provided, 
however,  that  the  amount  of  fat  partaken  of  be  not  too  large.* 
There  is  still  much  doubt  as  to  the  manner  in  which  bile  promotes 
fat  absorption.  We  know  that  it  favours  the  emulsification  of  fats. 
This  action,  according  to  IS[eumeister  ^^,  results  from  its  cholates, 
which  dissolve  the  potassium  and  magnesium  soaps  that  are  insol- 
uble in  the  other  fluids  of  the  small  intestine.  According  to  the 
more  recent  views  of  physiologists,  especially  those  of  Heidenhain  ^^, 
bile  promotes  the  entrance  of  fat  into  the  epithelial  cells  by  favour- 
ing fat  emulsification,  and  by  imparting  to  the  surface  of  the  cells  a 
capillarity  toward  fat.  Further  characteristics  ascribed  to  bile  are 
antiputrefactive  qualities  and  stimulation  of  intestinal  motions  (dogs 
with  biliary  fistula  and  human  beings  with  occlusion  of  the  bile 
passages  are  obstinately  constipated). f  The  latter  results  from  the 
free  bile  acids  which  normally  are  always  present  in  the  small  intes- 
tine. The  fseces  of  dogs  with  biliary  fistula  have  a  most  decided 
stench,  resulting  from  the  decomposition  of  carbohydrates.  Bile 
has  no  digestive  action  upon  albuminoid  bodies. 

INTESTINAL   PERISTALSIS 

(Motus  peristaltictis) 

The  object  of  intestinal  peristalsis  is  to  secure  a  mingling  of  the 
contents  and  their  onward  propulsion.  Thus  not  only  is  the  pabu- 
lum brought  into  intimate  contact  with  the  digestive  juices,  but  as 
soon  as  this  is  accomplished  the  contents  are  further  conducted 
through  successive  portions  of  the  intestines,  and  thereby  thorough 
absorption  is  secured.  From  this  it  follows  that  the  small  intestines 
are  mostly  concerned  with  peristalsis,  and  that  peristalsis  takes  place 
almost  exclusively  during  the  act  of  digestion. 

*  Compare,  for  example,  Mayo  Robson,  Proc.  Roy.  Soc,  vol.  xlvii,  1890,  pp. 
499-524 ;  Copemann  and  Winston,  Jour,  of  Physiology,  vol.  x,  1889,  pp.  213-231 ; 
Noel  Paton  and  John  Balfour,  Laboratory  Reports  issued  by  the  Royal  College  of 
Physicians,  Edinburgh,  1891,  vol.  iii,  pp.  191-240  (cited  from  Gamgee,  Physiolog- 
ische Chemie  der  Verdauung,  1897,  p.  288). 

f  As  far  as  man  is  concerned,  I  can  not,  in  general,  personally  confirm  this  rule, 
which  we  find  laid  down  with  the  greatest  certainty  in  almost  all  text-books  on 
physiology. 


32 


DISEASES  OP  THE  INTESTINES 


The  excellent  investigations  of  Braam-Houkgeest  ^,  of  Sanders- 
Ezn,  and  of  I^otlmagel  ^^,  who  studied  peristaltic  movements  in  ani- 
mals placed  in  physiological  salt  solution,  have  acquainted  us  fully 
witli  all  the  details.  We  may  distinguish  three  types  of  normal 
intestinal  movements :  peristalsis  proper,  pendulum  motion,  and 
rolling  motion. 

1.  In  ^peristalsis  jproper  there  is  a  widening  of  the  lumen  of  the 
gut,  followed  by  a  narrowing — a  wavelike  motion,  which  passes  with 
moderate  speed  over  a  certain  length  of  intestine  toward  the  anus, 
and  thereby  causes  a  visible  onward  propulsion  of  intestinal  con- 
tents. In  the  colon  the  peristaltic  wave  is  represented  by  depres- 
sions and  prominences  of  the  haustra  following  each  other  in  regu- 
lar succession. 

2.  Pendular  motions  are  always  limited  to  a  short  portion  of  the 
gut.  In  these  the  gut  is  moved  to  and  fro  without  any  perceptible 
change  in  the  width  of  its  lumen.  There  is  no  propulsion  of  the 
contents,  but,  instead,  a  mingling  of  the  same.  Propulsion  takes 
place  only  where  peristalsis  is  associated  with  pendular  motions,  a 
combination  which  has  been  observed.  According  to  Nothnagel, 
pendular  motions  may  be  seen  particularly^  in  the  middle  and  lower 
segments  of  the  intestines  when  these  are  tilled  with  pabulum.  The 
motions  may  last  as  long  as  fifteen  minutes,  when  they  suddenly 
cease,  to  begin  again  after  a  long  time  (one  hour  to  an  hour  and  a 
half)  without  any  special  cause.  This  period  of  cessation  is  said  to 
be  shorter  in  the  lower  portion  of  the  ileum  only.  Braam-Houk- 
geest observed  pendular  motion  in  empty  as  well  as  filled  intestines ; 
Nothnagel  in  the  latter  only. 

3.  Rolling  motions  occur  where  a  segment  of  the  gut  is  strongly 
distended  by  gas  and  at  the  same  time  has  fluid  contents.  Such  a 
segment  is  from  10  to  20  centimetres  long.  Its  contents  are  pro- 
pelled with  a  rapidity  closely  resembling  a  condition  known  as 
violent  peristalsis.  The  following  is  I^othnagel's  classical  descrip- 
tion : 

"  A  circular  constriction  constantly  progresses  behind  the  dis- 
tended intestinal  coils,  causing  such  a  propulsion  of  the  fluid  and 
gaseous  contents  toward  the  csecum  that  the  widely  distended  in- 
testinal parts  roll  about  like  a  wheel  quickly  revolving  in  water. 
And  now  a  surprising  occurrence  is  often  observed :  without  the 
slightest  external  cause,  the  peristalsis  may  suddenly  cease  at  any 
segment  whatever,  to  begin  very  strongly  again  after  an  indeflnite 
interval." 


PHYSIOLOGICAL  AND  PHYSIOLOGICO-CHEMICAL  REMARKS     33 

An  analogy  to  these  movements  is  furnished  us  by  the  familiar 
violent  peristalsis  {tormina  intsstinorum)  often  experienced  very 
soon  after  a  serious  dietetic  error.  But,  as  JS^othnagel  distinctly  em- 
phasizes, these  movements  do  not  involve  the  entire  length  of  the 
small  intestine ;  they  completely  cease  after  rapidly  passing  along  a 
limited  portion,  and  suddenly  and  without  apparent  cause  begin 
anew  in  another  portion.  They  are  most  active  in  the  duodenum 
and  jejunum ;  movements  in  the  duodenum  being  excited  by  the 
bile  and  pancreatic  secretion.  Farther  down  in  the  small  intestine 
the  peristaltic  waves  are  less  frequent  and  slower. 

In  consequence  of  the  peristaltic  action  of  the  small  intestine, 
the  pabulum  from  a  large  meal  passes  in  from  two  and  a  half  to 
three  hours  from  the  j^ylorus  to  the  ileocecal  valve;  whereas,  owing 
to  slowness  of  peristalsis  in  the  large  intestines,  food  requires  at 
least  twelve  hours  to  pass  through  the  much  shorter  distance  be- 
tween the  caecum  and  the  rectum. 

According  to  investigations  of  Braam-Houkgeest,  which  have 
been  fully  verified  by  Nothnagel,  peristaltic  movements  in  normal 
intestine  with  free  lumen  proceed  always  toward  the  anus  and  never 
toward  the  pylorus.  ISTothnagel  therefore  rejects  the  occurrence 
of  antiperistalsis,  such  as  has  been  described  by  older  investigators, 
particularly  Engelmann,  as  taking  place  physiologically.  There 
appeared,  however,  to  be  two  exceptions :  When  ]^othnagel  intro- 
duced active  irritative  fluids  (e.  g.,  concentrated  solutions  of  sodium 
chlorid,  of  potassium  nitrate  or  bromate,  or  weak  solutions  of  sul- 
phate of  copper)  into  the  rectum  of  rabbits,  he  observed  antiperi- 
staltic movements  as  far  as  the  caecum,  but  these  movements  could 
be  induced  from  the  rectum  alone ;  they  were  never  evoked  by  irri- 
tative solutions  of  salt  introduced  through  the  stomach.  Even  after 
artificially  produced  acute  intestinal  obstruction  in  animals,  ISToth- 
nagel did  not  observe  antiperistalsis.  There  was,  indeed,  a  backward 
movement  of  the  intestinal  contents ;  this  resulted,  however,  not 
from  antiperistalsis,  but  rather  from  a  procedure  which  ISTothnagel 
has  designated  "  recoil  contraction."  In  consequence  of  the  lively 
peristalsis  and  of  the  increase  in  intestinal  secretions  above  the 
stenosis,  there  is  a  large  accumulation  of  the  contents  in  the  supra- 
stenotic  part.  As  the  wall  of  the  gut  becomes  distended,  the  por- 
tion immediately  above  the  stenosis  contracts  strongly;  this  may 
result  in  forcing  the  contents  upward.  JiSTothnagel  does  not  believe 
that  the  regurgitation  of  intestinal  contents  in  intestinal  obstruction 
is  brought  about  in  this  manner,  but  maintains  that  it  results  from 


34  DISEASES   OF  THE   INTESTINES 

pressure  of  the  abdomen  upon  the  distended  paretic  wall  of  intes- 
tines above  the  stenosis. 

The  above-mentioned  investigations  of  Nothnagel  show  that  no 
backward  peristaltic  waves  can  be  observed  in  the  physiologically 
functionating  intestine. 

A  different  condition  can  be  observed  when  we  employ  mild 
irritants,  such  as  injections  of  normal  salt  solution,  which  to  a  cer- 
tain extent  are  still  physiological.  Thus  Grützner  ^^  has  lately 
called  attention  to  the  interesting  fact  that  the  injection  of  physio- 
logical salt  solution  into  the  rectum  of  man  and  the  lower  animals 
produces  antiperistaltic  movements,  which  involve  not  only  a  short 
segment,  but  also  the  entire  intestine  up  to  the  duodenum  ;  further- 
more. Grützner  showed  hereby  that  small  solid  particles  (starch 
granules,  haii's,  charcoal,  etc.)  which  are  suspended  in  the  injected 
fluids  are  carried  up  to  the  duodenum,  or  even  in  part  to  the  stom- 
ach, being  found  in  the  wash  water  from  the  latter  organ. 

Simultaneously  with  these  antiperistaltic  movements,  which 
pass  immediately  next  to  the  mucous  membrane,  there  also  occur 
peristaltic  movements  by  which  faeces  and  chyme  are  brought  down- 
ward. 

Thus  far  control  examinations  by  others  do  not  entirely  confirm 
Grützner's  conclusions.  Christomanos^,  Dauber^,  and  Wendt^ 
think  positive  results  were  obtained  because  the  animals  licked 
their  own  intestinal  evacuations ;  where  this  was  carefully  guarded 
against,  negative  results  were  obtained.  By  experiments  upon 
human  subjects,  Swiezynski^  was  able  to  demonstrate  that  lycopo- 
dium  introduced  into  the  rectum  passed  upward  into  the  stomach. 
He,  however,  was  unable  to  determine  with  certainty  the  part  which 
sodium  chlorid  played  in  this  experiment.  Be  this  as  it  may,  the 
investigations  of  Grützner  do  not  prove  the  occurrence  of  a  true 
antiperistalsis,  but  only  show  that  food  stuffs  introduced  into  the 
rectum  may  pass  upward  within  the  intestine.  We  fully  coincide 
with  Riegel  ^\  who  regards  the  superficial  epithelium  of  the  intes- 
tines as  the  chief  causative  factor  in  this  upward  movement. 

Wherein  lies  the  impulse  for  intestinal  movements  ?  Investiga- 
tions made  thus  far  upon  this  point  show  that  the  intestinal  wall  has 
automatic  movement  centres  similar  to  those  of  the  heart,  and, 
furthermore,  that  the  central  nervous  system  exerts  an  important 
influence  upon  physiological  and  pathological  intestinal  movements. 
The  principal  seat  of  the  automatic  centres  is  very  probably  the 
nerve  and  ganglion  plexuses  of  Meissner  and  of  Auerbach.     ]^oth- 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL   REMARKS     35 

nagel  could  elicit  intestinal  movements  bj  touching  various  spots  in 
the  intestines  with  a  sodium  or  a  potassium  salt,  and  thus  proved 
beyond  all  doubt  the  jjresence  of  nerve  centres  within  the  wall  of 
the  intestines. 

The  relations  between  the  cerebro-spinal  nervous  system  and 
intestinal  movements  are  very  complicated.  The  pneumogastric 
undoubtedly  plays  a  certain  part  here,  for  irritation  of  that  nerve 
causes  or  increases  a  movement  throughout  the  entire  small,  and 
the  upper  portion  of  the  large,  intestine.  The  entire  large  intestine, 
according  to  the  latest  researches  of  Pal  ^,  receives  motor  fibres  from 
the  pneumogastric.  We  know  from  Piiüger's  celebrated  experi- 
ments that  the  splanchnic  nerve  inhibits  intestinal  peristalsis.  This 
inhibition  may  be  direct,  or  it  may  be  brought  about  indirectly  by 
the  anaemia  which  results  from  irritations  of  the  splanchnic.  Ac- 
cording to  the  most  recent  experiments  of  S.  Mayer  and  von  Basch, 
the  splanchnic  nerve  exerts  an  inhibitory  influence  only  as  long  as 
the  blood  in  the  capillaries  is  not  venous ;  when  the  blood  becomes 
venous,  then  stimulation  of  this  nerve  causes  increased  peristalsis. 
Investigations  of  Nasse  show  that  the  splanchnic  also  contains  direct 
motor  fibres,  but  PaP^  concludes  from  his  experiments  that  the 
action  obtained  is  a  reflex  one.  In  like  manner,  stimulation  of  the 
cortex  of  the  brain  and  of  the  optic  thalamus  may  inhibit  or  accel- 
erate intestinal  movements  :  the  acceleratory  stimulus  passes  through 
the  pneumogastric,  the  inhibitory  through  the  spinal  cord  (Bechte- 
rew and  Mislowski  ^). 

J.  PaP^  has  furthermore  shown  that  the  splanchnic  centre  is  not 
the  only  inhibitory  one  of  the  small  intestines,  but  that  there  are 
others  lower  down  in  the  spinal  cord. 

Contrary  to  the  small  intestines  and  the  upper  part  of  the  large, 
the  lower  part  of  the  large  intestine  and  the  rectum  receive  inhib- 
itory as  well  as  acceleratory  fibres  from  the  sympathetic. 

In  connection  with  innervation  of  the  rectum,  Fellner  "  has  called  attention 
to  a  remarkable  antagonism  existing  between  the  nervi  erigentes  and  the  nervi 
hypogastrici  of  the  dog.  Whereas  the  former  nerves  contain  motor  fibres  for 
the  longitudinal  and  inhibitory  for  the  circular  muscles,  the  reverse  is  true  of 
the  hypogastric.  L.  Exner  *^  disputes  the  evidences  lent  by  Fellner's  experi- 
ments, but  they  have  recently  been  confirmed  by  Pal  *^. 

l^ormal  peristalsis  may  be  increased  or  diminished  through  ex- 
ternal as  well  as  internal  agencies.  The  external  agencies  include 
cold,  massage,  and  the  faradic  current ;  the  internal,  mechanical, 
chemical  and  thermal,  vaso-motor  and  central  stimulation.     Those 


36  DISEASES  OP  THE  INTESTINES 

mechanical  agencies  which  cause  an  increase  in  normal  peristaltic 
movement  are  foreign  bodies,  stenoses,  parasites,  and  particularly 
indigestible  foods ;  the  chemical  agencies  include  laxatives  and 
tainted  food  stuffs,  with  their  accompanying  products  of  decomposi- 
tion. The  thermic  excitants  of  peristalsis  are  cold,  especially  in  the 
form  of  cold  drinks,  ice,  or  of  cold  injections.  Circulatory  disturb- 
ances resulting  from  congestion  of  the  portal  system  may  cause  an 
increase  or  a  slowing  of  peristalsis.  Finally,  we  may  have  increased 
peristalsis  resulting  from  certain  conditions  of  the  central  nervous 
system — e.  g.,  crises  enteriques  of  tabes,  tormina  ventricuh  nervosa 
(Kussmaul),  in  neurasthenics,  hysterics,  etc. 

Conversely,  similar  conditions  may  cause  the  peristalsis  to  dimin- 
ish, or  to  cease  entirely.  Mechanical  causes  are  very  frequently 
found  in  women;  retroflexion  of  the  uterus  is  one  of  the  best 
knoAvn,  although  not  the  only  example. 

As  examples  of  thermal  sedatives,  we  have  warm,  moist  applica- 
tions (cataplasma)  and  warm  enemata.  Where  we  have  increased 
intestinal  movements,  the  diet  employed  may,  from  its  nature,  act 
as  a  chemical  sedative — e.  g.,  gruels  in  diarrhoeas.  The  narcotic 
drugs  (opium  and  its  derivatives,  belladonna,  etc.)  should  be  classed 
with  those  chemical  agents  which  diminish  intestinal  peristalsis. 
The  latter  may  also  be  indirectly  influenced  by  remedies  which 
tend  to  diminish  intestinal  secretion  (the  so-called  astringents). 

In  the  course  of  many  diseases  of  the  intestinal  mucous  mem- 
brane there  is  a  gradual  decrease  in  normal  intestinal  excitability. 
In  intestinal  stenosis  we  may  have  a  temporary  or  a  permanent 
paralysis,  resulting  from  paretic  effects  of  fluid  or  gaseous  prod- 
ucts. Disturbances  of  intestinal  circulation  (haemorrhoids,  con- 
gestion accompanying  uncompensated  valvular  affections,  etc.) 
frequently  cause  a  decided  slowing  of  peristalsis.  Furthermore, 
central  nervous  impulses  may  not  only  accelerate,  but  may  weaken 
or  even  inhibit  intestinal  movements — e.  g.,  meningitis,  cerebral  tu- 
mours, etc.  In  functional  neuroses  (neurasthenia,  hypochondriasis, 
and  hysteria)  there  may  be  a  marked  diminution  in  the  peristaltic 
movements.  Lastly,  feeble  peristalsis  has  been  observed  as  a  con- 
genital inherited  condition. 

INTESTINAL   ABSORPTION 

The  intestinal  canal  is  the  principal  seat  of  food  absorption. 
As  has  been  proved  by  the  most  recent  researches  of  von  Mering, 


PHYSIOLOarCAL  AND  PHYSIOLOGICO-CHEMICAL  EEMARKS     37 

Moritz,  Hirsch,  and  Brandt,  the  absorption  of  substances  (even 
in  solution)  from  the  stomach  is  very  limited.  It  has  been  dem- 
onstrated that  besides  water,  the  intestines  also  absorb  peptones 
(or  albumoses)  as  well  as  the  various  saccharins,  salt  solutions, 
and  fats,  and  give  up  these  substances  to  the  lymph  and  blood 
channels. 

Formerly  absorption  was  regarded  as  a  purely  physical  process — 
for  the  most  part  one  of  simple  diffusion.  But  since  colloids  (albu- 
mins and  gelatins)  have  very  poor  osmotic  properties,  this  explana- 
tion would  apply  to  crystalloid  substances  only  (salt  and  sugar). 
Furthermore,  this  theory  does  not  account  for  the  entrance  of  the 
fats  into  the  chyle.  The  view  which  is  now  accepted  is  that  absorp- 
tion of  food  particles  results  mainly  from  a  specific  function  of  the 
living  protoplasm.  This  theory  has  sprung  up  within  recent  years, 
and  has  been  evolved  from  the  studies  of  Iloppe-Seyler,  Heiden- 
hain, I.  Munk,  and  others. 

We  shall  now  briefly  describe  the  manner  in  which  absorption 
takes  place  in  the  intestines.  First,  as  regards  the  absorption  of 
peptones.  It  is  well  known  that  peptones  do  not  enter  the  blood 
current  as  such,  but  in  the  form  of  albuminoids.  This  change  is 
essential,  for  it  has  been  proved  that  peptones  injected  into  the 
blood  are  quickly  excreted  by  the  urine  (Plosz  and  Gyergyay'**, 
Hofmeister  ^^).  Consequently  peptones  must  be  converted  into 
albuminoid  bodies  before  they  enter  the  blood.  Opinion  is  divided 
among  physiologists  as  to  where  this  conversion  takes  place.  Thus 
Hofmeister  ^^  ascribes  the  greater  importance  in  assimilation  and 
absorption  of  the  proteids  to  the  leucocytes  found  so  plentifully 
upon  the  surface  of  the  intestine  during  digestion  ;  whereas  Heiden- 
hain ^^  credits  the  leucocytes  with  but  a  very  minor  part  in  the 
reconversion  of  albuminoids  from  peptones,  and  ascribes  this  rather 
to  the  epithehal  layer  of  the  villi. 

It  is  important  to  inquire  into  the  utilization  of  albuminoids 
where  pancreatic  juice  is  entirely  absent.  After  complete  extirpa- 
tion of  the  pancreas  in  dogs.  Abelmann*'''  and  Minkowski  found 
an  average  utilization  of  44  per  cent  of  albumin  ingested,  while, 
after  partial  extirpation,  54  per  cent  was  utilized.  Similar  experi- 
ments of  Sandmeyer^  showed  a  utilization  of  from  62  per  cent 
to  70  per  cent,  which  was  markedly  increased  by  the  administration 
of  raw  beef  pancreas.  In  the  latter  instance,  figures  coinciding 
fully  with  those  from  normal  animals  were  obtained. 

As  regards  absorption  of  the  carbohydrates,  that  of  glucose 
4 


38  DISEASES  OF  THE  INTESTINES 

levulose  and  galactose  is  direct,  while  maltose  and  cane  sugar  are 
iirst  converted  into  glucose  within  the  intestines,  and  as  such  are  then 
absorbed.  Experiments  of  Ludwig  and  von  Mering^^  upon  lower 
animals,  and  of  I.  Munk  and  Rosenstein  ^  upon  man,  tend  to  show 
that  carbohydrates  are  not  absorbed  through  the  chyle  vessels,  but 
pass  directly  into  the  blood.  Should  there  be  an  excess  of  blood 
in  the  intestine,  some  of  the  sugar  will  pass  directly  into  the  chyle 
vessels  and  into  the  thoracic  duct  (Ginsberg  ^^).  It  appears  from 
the  investigations  of  Hoppe-Seyler^,  von  Mering^**,  and  Otto^^,  that 
cane  sugar  as  well  as  dextrinlike  substances  may  be  found  in  the 
blood,  though  only  in  small  quantities. 

There  is  also  a  limit  to  the  amount  of  sugar  which  can  be  con- 
veyed to  the  blood-vessels  of  the  liver ;  when  this  limit  is  exceeded, 
the  excess  in  all  probability  passes  directly  into  the  lymphatic  sys- 
tem and  is  not  brought  to  the  liver  at  all.  A  portion  of  it  readily 
appears  in  the  urine  (alimentary  glycosuria).  The  so-called  "limit 
of  assimilation "  varies  with  the  individual  person  as  well  as  with 
the  variety  of  sugar.*  Sugar  is  stored  up  in  the  liver  and  to  a  less 
extent  in  the  muscles  and  glands,  in  the  form  of  glycogen,  a  non- 
oxidizable  substance.  The  pancreas  is  the  main  though  not  the 
only  factor  in  the  digestion  and  absorption  of  sugars.  Although 
Minkowski  and  Abelmann  ^'^  found  that  only  5Y  to  61  per  cent  of 
starches  were  absorbed  after  total  extirpation  of  the  pancreas  in 
dogs,  the  experiments  of  Fr.  Müller  ^^  on  man  have  nevertheless 
shown  that,  even  with  total  occlusion  of  the  pancreatic  duct,  starches 
are  absorbed  with  hardly  any  loss  whatever. 

Fats  are  absorbed  in  the  intestines  after  previous  emulsification 
by  the  pancreatic  secretion  and  the  bile.  Owing  to  the  great  abun- 
dance of  alkalies  present,  the  fatty  acids  are  converted  into  soaps. 
Fats  are  very  probably  absorbed  through  the  lymphatics.  This  has 
been  proved  by  the  investigations  of  Munk  and  Rosen  stein  ^^  in 
their  case  of  lymphatic  fistula.  In  their  experiments  they  found  60 
per  cent  of  the  fats  originally  given  in  the  chyle,  and  only  4  to  5 
per  cent  of  that  amount  was  saponified.  Furthermore,  upon  feed- 
ing with  erucic  acid,  a  fat  entirely  foreign  to  the  body,  they  again 
obtained  37  per  cent,  and  this  in  the  form  of  neutral  fat.  It  follows 
from  this  that  the  fatty  acids  do  not  enter  the  lacteals  in  their  orig- 
inal form,  but  as  neutral  fats.  I.  Munk  assumes  also  that  fatty  soaps 
are  for  the  greatest  part  converted  into  neutral  fats  before  entering 
the  lymphatics. 

*  Compare  von  Noorden,  Pathologie  des  Stoffwechsels,  Berlin,  1893. 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL  REMARKS     39 

To  sum  up,  absorption  of  the  fatty  portion  of  the  food  takes 
place  as  follows  :  1.  Finely  emulsified  fat,  as  such,  is  either  taken  up 
by  the  migratory  lymph  cells  lying  upon  the  free  surface  of  the 
intestinal  wall  (Zawarykin^*  and  Wiedersheim^^),  or  else  it  passes 
directly  into  the  villi,  entering  between  the  spaces  at  the  base  of  the 
cylindrical  epithelia  (Heidenhain).  2.  Fatty  acids  are  converted 
into  neutral  fats,  and.  are  likewise  taken  up  by  the  lymphatics. 
3.  Fatty  soaps  are  reconverted  into  neutral  fats  and  taken  up  by 
the  lymphatics.  Since  fatty  acids,  as  such,  are  not  found  again  in 
the  chyle,  we  must  assume  with  I.  Munk^^  and  von  Walther^*^  that 
they  are  converted  within  the  intestinal  wall  into  neutral  fats  by  the 
addition  of  glycerin,  or  even  upon  the  intestinal  surface  itself  (von 
Walther). 

As  regards  the  soajjs,  it  would  appear  as  though  they  could 
combine  with  glycerin  to  form  neutral  fats  within  the  parenchyma 
of  the  villi.  We  must,  however,  admit  the  impossibility  of  explain- 
ing the  source  of  the  glycerin  necessary  for  this  change.  Possibly  it 
may  be  a  portion  of  that  made  free  in  the  splitting  up  of  fat  by  the 
pancreatic  secretion  ;  at  all  events,  the  investigations  of  Perewozisn- 
koff  ^^,  and  the  later  ones  of  WilP^  and  C.  A.  Ewald  ®'^,  have  shown 
that  the  living  intestine  is  capable  of  forming  neutral  fats  when 
the  component  parts,  fatty  acids  and  glycerin,  or  fatty  soaps  and 
glycerin,  are  introduced  into  it.  Neumeister  ^  quite  correctly 
points  out  that  the  epithelial  cells  play  an  important  part  in  this 
conversion. 

Variety  and  constituency  of  the  fats  are  of  great  importance  in 
determining  their  digestibility.  I.  Munk^^  and  Arnschink^^  have 
shown  that  fats  with  a  high  melting  point  (mutton  tallow,  stearin, 
etc.)  are  not  so  completely  absorbed  as  the  more  easily  melted  fats 
(lard,  goose  fat,  olive  oil,  butter,  etc.).  According  to  Munk  and 
Rosenstein  ^,  a  firm  fat  like  mutton  tallow  is  more  slowly  absorbed 
than  a  fluid  like  lipanin.  Besides  this,  a  free  fat  is  more  readily 
absorbed  than  one  which,  like  lard,  is  inclosed  in  an  envelope 
(Rubner^^).  I  find  interesting  the  fact  mentioned  by  Fleischer^, 
that  Hippocrates  had  already  referred  the  difiiculty  in  the  digesti- 
bility of  eels  to  the  stearin  contained  in  them. 

How  does  occlusion  of  the  pancreatic  duct  or  extirpation  of  the 
pancreas  affect  fat  digestion  ?  The  absence  of  pancreatic  juice  is 
certainly  of  great  importance  in  this  connection.  According  to 
Minkowski  and  Abelmann  ^''',  all  fats  (neutral  as  well  as  mixtures 
of  fatty  soaps  and  fatty  acids)  fed  to  dogs  under  these  conditions 


40  DISEASES  OP  THE  INTESTINES 

appear  in  the  feces.  Milk  forms  the  only  exception;  over  half 
of  its  fat  is  absorbed.  An  increase  in  the  absorption  of  fat  was 
observed  when  pancreas  of  beef  or  pig  was  added  to  the  food. 
Other  experiments  upon  the  absorption  of  fat,  especially  in  man,  con- 
trast with  the  results  just  cited.  Thus  Sandmeyer^  found  great 
variations  in  the  absorption  of  unemulsified  fats  in  his  dogs  (0-78 
per  cent).  "Where  emulsified  fats  in  the  form  of  milk  were  given, 
42  per  cent  was  absorbed.  Teichmann  ^  found  no  altei-ation  in 
fat  absorption  in  rabbits  in  whom  the  pancreatic  duct  had  been 
tied.  Fr.  Müller  ^  found  rather  abundant  fat  absorption  in  a  case 
of  pancreatic  fistula  consequent  upon  the  extirpation  of  a  cyst. 

Though  the  results  just  enumerated  are  so  very  contradictory,  it 
is  not  incorrect  to  assume  that  disturbances  in  the  assimilation  of 
fat  arise  wherever  there  is  a  long-continued  exclusion  of  pancreatic 
juices,  and  (as  is  usually  the  case  in  man)  also  of  the  bile.  From 
this  it  by  no  means  follows  that  these  secretions  are  indispensable 
to  the  support  of  life,  for  there  are  apparently  vicarious  forces  which 
to  a  certain  extent  can  offset  the  disturbances  occasioned  by  the 
absence  of  these  digestive  secretions. 

Absorption  from  the  large  intestine  is  relatively  unimportant. 
However,  when  the  activity  of  the  upper  portions  of  the  absorptive 
system  is  in  abeyance,  the  large  intestine  may  for  a  time  act 
vicariously.  This  we  learn  from  the  employment  of  rectal  nutri- 
tion. Water,  especially,  is  very  readily  absorbed  from  the  large 
intestine.  As  proved  by  Eichhorst  ^^,  Yoit  and  Bauer  %  Leube^, 
Ewald  ®^,  Huber^'',  and  Kohlenberger'''^,  albuminoids  and  albumoses 
are  also  absorbed  from  the  rectum  and  the  large  intestine.  My 
own  experience  with  milk  has  taught  me  that  it  is  almost  entirely 
absorbed  from  the  lower  segment  of  the  large  intestine.  Starch 
which  has  not  been  converted  into  sugar  is  slowly  acted  upon  by  the 
bacterial  ferments,  and  ultimately  decomposed  into  lactic  acid,  buty- 
ric acid,  etc. 

Eats,  especially  emulsified  fats,  are  slowly  absorbed  from  the  large 
intestine  (Kobert'''^  Munk  and  Rosenstein  ^^,  P.  Deucher"^^).  The 
amount  taken  up  is,  however,  comparatively  slight,  only  10  per 
cent  of  that  present  in  a  rectal  injection  being  absorbed  (Deucher). 
The  absorption  of  oils  may  be  increased  by  the  addition  of  normal 
salt  solution. 

The  immediate  result  of  a  liberal  absorption  of  food  constituents 
from  the  intestines  is  a  gradual  increase  in  the  consistency  of  the 
residue,  which  slowly  assumes  the  form  of  normal  faeces.     At  the 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL  REMARKS     41 

same  time  the  acid  reaction  of  the  masses  becomes  gradually  neutral 
or  feebly  alkaline. 

THE  EXCRETORY  FUNCTION  OF  THE  INTESTINAL 

CANAL 

Besides  absorption  and  secretion,  the  intestinal  canal,  like  the 
stomach,  has  also  the  function  of  excretion.  It  may  thus  rid  itself 
of  superfluous  substances'  as  well  as  of  waste  materials  from  the 
blood,  all  of  which  it  excretes  with  the  fseces.  This  function  of  the 
intestines,  which  has  been  closely  studied  within  the  last  few  years, 
is  also  of  clinical  interest,  and  therefore  deserves  brief  mention. 

We  know  from  Hermann's  experiments''^*  with  animals,  but 
even  more  so  from  Fr.  Müller's  experiments''^,  in  connection  with 
Senator,  Lehmann,  I.  Munk,  and  Salkowski,  upon  the  two  profes- 
sional fasters  Cetti  and  Breithaupt,  that  during  fasting  the  faeces 
contain  a  number  of  organic  and  inorganic  substances,  a  portion  of 
which,  at  least,  must  be  regarded  as  excreted  matter.  Kobert  '^^  de- 
serves credit  for  having  made  similar  studies  upon  the  isolated  large 
intestine  of  men,  and  for  having  thus  determined  the  share  taken  in 
excretion  by  that  portion  of  the  intestinal  canal.  He  found  that  in 
twenty-four  hours  an  inactive  large  intestine  excreted  an  average  of 
0.9684  grammes  dry  substance,  the  percentage  of  whose  ingredients 
varied  from  3.35  per  cent  inorganic  and  96.65  per  cent  organic 
ingredients,  to  57.52  per  cent  inorganic  and  42.48  per  cent  organic 
substances.  The  inorganic  ingredients  were  sodium,  calcium,  mag- 
nesium, iron,  and  phosphoric,  sulphuric,  and  hydrochloric  acids; 
the  organic,  mucin,  albumin,  keratin,  fatty  acids,  soaps,  and  neu- 
tral fats.  A  large  proportion  (12.793  per  cent)  of  the  inorganic 
substances  consisted  of  calcium  and  of  phosphoric  acid  (44.52  per 
cent).  This  substantiates  the  results  of  Fr.  Müller's  experiments 
on  dogs,  as  well  as  those  of  von  Noorden  and  Belgardt  '^^  on  man,  in 
which  they  found  large  amounts  of  calcium  and  phosphates  in  the 
excretions,  particularly  in  those  from  the  large  intestine.  From 
investigations  in  a  case  of  fistula  of  the  ileum,  Honigman  '^'^  recently 
arrived  at  the  same  conclusions.  Particular  interest  lends  itself 
to  the  discovery  made  by  Kobert,  that  the  large  intestine  can  also 
excrete  fat.  He  found  that  the  total  amount  varies  from  9.32  per 
cent  to  6.48  per  cent  of  the  dried  substance ;  90  per  cent  of  this 
total  amount  being  fatty  acids,  9  per  cent  neutral  fats,  and  the 
remainder  fatty  soaps.     From  this  it  may  be  seen   that  intestinal 


42 


DISEASES   OF   THE  INTESTINES 


excretion  constitutes  an  important  auxiliary  to  tlie  functions  of 
the  kidney.  The  occurrence  of  profuse  diarrhoeas  in  extensive 
parenchymatous  changes  of  the  kidneys  is  in  all  probability  an 
attempt  on  the  part  of  the  organism  to  vicariously  rid  itself  of  waste 
material  through  the  intestinal  canal.  From  investigations  thus  far 
made,  we  would  regard  the  large  intestine  as  most  actively  partici- 
pating in  this  vicarious  action. 

THE  NATURE  AND  COMPOSITION  OF  THE  F>CCES 

The  fseces  are  made  up  partly  of  food  which  is  either  indiges- 
tible or  has  not  been  acted  upon  by  the  digestive  juices,  partly  of 
the  secondary  products  of  digestion,  and  lastly  from  the  remnants 
of  the  secretions  and  excretions  of  the  digestive  tract  itself.  In 
this  latter  connection  it  should  be  remarked  that  the  empty  intes- 
tine may  produce  faeces  through  its  secretions  and  its  exfoliated 
epithelium  (so-called  RingJcoth  of  L.  Hermann  '^^). 

The  composition  of  the  fseces  naturally  varies  very  much  accord- 
ing to  the  nature  and  range  of  the  diet.  Under  a  vegetable  diet 
the  fjecal  masses  are  much  bulkier  than  under  an  animal  one.  As 
an  example  of  this,  Yoit  "'^  states  that  the  excrements  of  a  man  under 
a  mixed  diet  amounted  to  120-150  grams,  vnth  30-37  grams  solids 
in  twenty -four  hours  ;  while  those  from  a  vegetarian  equalled  333 
grams,  with  75  grams  solids.  The  colour  of  the  fseces  is  to  a  cer- 
tain degree  also  dependent  upon  the  diet.  Under  mixed  diet  it 
is  dark  brown  ;  under  milk  diet,  brownish  yellow ;  and  brownish 
black,  or  even  deep  black,  under  meat  diet. 

Among  the  food  ingredients  found  in  normal  fseces  are  muscle 
fibres,  connective  tissue,  casein  particles,  starch  fragments,  fat,  vege- 
table remnants,  horny  substances,  nuclein,  etc.  The  intestinal  mu- 
cous membrane  and  its  secretions  contribute  mucin,  cholic  acid, 
dysalin,  and  Cholesterin.  The  products  of  intestinal  putrefaction 
found  in  the  fseces  include  skatol,  indol,  volatile  fatty  acids  (acetic 
acid  is  said  to  be  constantly  present  in  fseces),  calcium,  and  magne- 
sium soaps.  Of  the  inorganic  salts  in  the  fseces,  the  readily  soluble 
alkaline  chlorids  occur  but  rarely,  while  the  insoluble  combinations 
— ammonium  magnesium  phosphates,  calcium  carbonate,  neutral 
calcium  phosphate,  and  magnesium  phosphate — are,  on  the  con- 
trary, very  frequently  met  with,  being  for  the  most  part  derived 
from  the  food. 

Bacteria  and  other  micro-organisms  occur  in  large  numbers  in 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL   REMARKS     43 

the  fseces ;  according  to  Woodward  ""^j  thej  constitute  a  very  con- 
siderable portion  of  the  faeces.  The  only  bile  pigment  found  under 
norncial  conditions  is  urobilin  (stercobilin) ;  the  occurrence  of  biliru- 
bin or  biliverdin  is  pathologic. 

Careful  quantitative  analyses  of  the  faeces  have  often  been  made, 
but,  as  might  have  been  supposed,  they  have  given  widely  varying 
results.     We  would  therefore  desist  from  mentioning  them. 

INTESTINAL   DIGESTION    IN    ITS    ENTIRETY 

In  attempting  a  description  of  intestinal  digestion  in  toto,  we 
encounter  serious  obstacles;  for  our  knowledge  of  this  subject  in- 
cludes a  number  of  isolated  processes  which  can  not  be  grouped 
together  without  the  aid  of  some  hypotheses. 

What  impulse  excites  intestinal  secretion  ?  The  opening  of  the 
pylorus  acting  reflexly  very  likely  causes  an  increased  secretion  of 
bile  and  of  pancreatic  juice.  Concerning  the  pancreatic  secretion, 
we  know  from  the  experiments  of  Heidenhain  ^°  and  Bernstein  ^^ 
that  it  begins  to  flow  simultaneously  with  the  ingestion  of  food,  and 
reaches  its  maximum  in  from  two  to  three  hours.  Thereupon  the 
amount  declines  till  the  fifth  to  the  seventh  hour,  increasing  anew 
from  the  ninth  to  the  eleventh,  and  then  gradually  declining  again 
from  the  seventeenth  to  the  twenty-fourth  hour,  when  it  finally 
ceases. 

As  regards  the  bile,  we  know  that  it  decreases  during  fasting,  • 
and  is  secreted  again  after  ingestion  of  food.  According  to  Heiden- 
hain, two  maxima  in  rapidity  of  its  secretion  are  observed  in  dogs : 
the  first  from  three  to  five  hours  after  food  ingestion,  and  the 
second  from  thirteen  to  fifteen  hours.  Investigations  of  Rossbach  ^ 
yielded  similar  results.  In  all  probability,  therefore,  the  chyme 
meets  with  an  active  digestive  juice  when  it  enters  the  intestinal 
canal. 

The  action  of  the  intestinal  juices  upon  the  products  of  stomach 
digestion  is  still  a  matter  of  controversy.  Physiologists,  particu- 
larly Kühne,  ascribe  to  bile  the  property  of  precipitating  and 
destroying  not  only  the  albumin  and  gelatin,  but  also  the  pepsin 
of  the  stomach  contents.  From  this  it  would  seem  as  though 
the  precipitation  of  the  pepsin  within  the  small  intestines  was  of 
extreme  importance  for  digestion.  However,  my  own  investiga- 
tions ^°  made  with  the  pure  mixed  secretions  from  the  intestines 
of  man  (i.  e.,  mixtures  of  bile,  pancreatic  juice,  and  probably  also 


44  DISEASES   OF  THE  INTESTINES 

tlie  secretion  from  the  glands  of  Lieberkiilin)  have  shown  that  these 
views  are  incorrect.  What  does  occur  is  rather  as  follows :  The 
first  faintly  acid  portions  of  the  chjme  occasion  alterations  in  the 
intestinal  juices  onlj  in  so  far  as  they  acidify  these  to  a  slight 
degree,  whereby,  as  we  have  already  seen  (see  page  27),  no  de- 
struction of  the  active  intestinal  ferments  occurs.  It  is  true  that 
with  the  entrance  of  strongly  acid  chyme  into  the  small  intestine 
a  precipitation  of  the  albuminoids — but  not  of  the  gastric  ferments 
— follows.  However,  a  mixture  of  duodenal  juices  and  stomach 
contents  with  the  latter  in  such  proportion  that  free  hydrochloric 
acid  is  present  exhibits  solely  and  distinctly  the  characteristics  of 
a  pepsin-hydrochloric-acid  solution.  Kennet  ferment  also  is  pre- 
served intact  in  such  a  mixture.  If  we  alkalinize  such  a  mixture 
with  dilute  soda  solution,  we  may — for  a  short  time  at  least — be 
able  to  observe  tryptic  action.  Later  this  action  can  not  be  brought 
out  because  the  trypsin  is  destroyed  by  the  continued  action  of 
the  gastric  acid.  It  is  therefore  very  probable  that  in  the  first 
stages  of  intestinal  digestion  there  is  simply  a  continuation  of  the 
gastric  digestion.  Gradually,  however,  as  the  intestinal  juices  in- 
crease and  the  amount  of  strongly  acid  stomach  chyme  poured  into 
the  duodenum  diminishes,  pepsin  digestion  gives  way  to  that  of 
trypsin.  My  observations  have  recently,  in  great  part,  been  con- 
firmed by  Fleischer^  and  Meltzer. 

In  spite  of  the  differences  of  opinion  between  physiologist  and 
clinician,  the  above  observations  show  that  the  reaction  of  the  con- 
tents of  the  small  intestines  varies  according  to  the  stage  of  diges- 
tion. Even  in  the  lowermost  portion  of  the  small  intestines— as 
JSTencki,  Macfadyen  and  Sieber^  found  in  a  fistula  in  the  lowest 
portion  of  the  ileum — the  reaction  of  the  contents  was  acid,  the 
acidity  averaging  one  pro  miille  (basis  of  acetic  acid). 

As  soon  as  the  intestinal  ferments  can  act  with  full  force  the 
digestion  of  food  takes  place,  the  individual  ferments  acting  as 
already  described.  Proteids  which  have  not  yet  been  converted 
into  albumoses  are  peptonized,  with  the  additional  formation  of 
leucin,  tyrosin,  and  of  aspartic  acid  ;  unconverted  carbohydrates  are 
at  first  altered  into  maltose  and  (a  little)  glucose,  and  finally  com- 
pletely into  glucose ;  fats  are  split  up  into  fatty  acids  and  glycerin, 
and  are  in  part  emulsified — i.  e.,  brought  into  an  absorbable  con- 
dition. 

In  addition  to  these  fermentative  changes  there  are  also  bacterio- 
logical changes  which  to  a  certain  extent  affect  the  proteids  and 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL  REMARKS     45 

gelatinous  substances,  but  to  a  far  greater  degree  the  carbohydrates. 
Their  existence  has  been  proved  by  the  above-mentioned  instructive 
investigations  of  JSTencki,  Macfadyen  and  Sieber  ^  upon  their  case 
of  fistula  of  the  ileum.  The  chyme  vs^as  of  a  yellowish  or  yellowish- 
brown  colour  and  had  an  acid  reaction.  As  a  rule,  excepting  for  a 
somewhat  burnt  smell  reminding  one  of  the  volatile  fatty  acids,  or 
still  more  rarely  excepting  for  an  odour  of  decomposition  very  like 
indol,  this  yellowish  mass  was  entirely  odourless.  Besides  acetic 
acid,  fermentation  as  well  as  musclelactic  acicl,  volatile,  fatty,  suc- 
cinic, and  bile  acids  were  also  present.  In  large  quantities  of  this 
chyme  it  was  impossible  either  through  sense  of  smell  or  through 
chemical  examination  to  detect  the  merest  traces  of  the  character- 
istic decomposition  products,  such  as  indol,  skatol,  phenol,  methyl 
mercaptan,  or  of  their  combinations,  phenylpropionic  acid,  paraoxy- 
phenyl-propionic  acid,  and  skatolacetic  acid. 

Without  doubt  the  real  seat  of  intestinal  putrefaction  is  in  the 
large  intestine.  The  role  in  food  digestion  assumed  by  the  large 
intestine  is  markedly  less  than  that  of  the  small.  The  experiments 
of  Nencki,  Macfadyen  and  Sieber  showed  that  85  per  cent  of  the 
albumin  ingested  is  digected  by  and  absorbed  from  the  stomach  and 
small  intestines,  so  that  but  about  15  per  cent  remains  for  the  large 
intestines.  Undoubtedly  digestion  does  take  place  in  the  large 
intestine,  but  it  is  more  bacterial  than  fermentative.  Another  chief 
difference  from  small  intestinal  digestion  is  the  formation  not  only 
of  useful  products,  but  also  of  others  harmful  to  the  economy.  It 
is  questionable,  however,  if  all  bacterial  by-products  are  utterly  use- 
less in  intestinal  digestion — if,  for  example,  certain  products  are 
not  capable  of  favourably  exciting  peristaltic  motion. 

The  best-known  decomposition  products  are  those  of  albumin. 
They  have  been  studied  by  many  investigators,  above  all  by  l^encki. 
Baumann,  Brieger  and  H.  and  E.  Salkowski.  The  most  important 
are  indol,  skatol,  paracresol,  phenyl-propionic  acid,  phenyl-acetic 
acid,  hydroparakumaric  acid,  the  volatile  fatty  acids,  carbon-dioxide, 
hydrogen  gas,  methyl  mercaptan,  and  sulphuretted  hydrogen. 

Of  these,  the  most  important  from  a  practical  standpoint,  are 
indol  and  skatol,  because,  as  has  been  shown  by  the  investigations 
of  E.  Baumann,  they  combine  with  the  sulphates  of  the  food  (pre- 
viously oxidized  to  indoxyl  and  skatoxyl  sulphates)  to  form  ethereal 
sulphuric  acids  (indoxyl-sulphuric  acid  and  skatoxyl-sulphuric  acid), 
and  are  excreted  as  such  in  the  urine.  They  thus  form  a  gauge 
(though  not  a  constant  one)  for  the  putrefactive  processes  within  the 


46  DISEASES  OP  THE  INTESTINES 

intestines.     Phenol  passes  into  the  urine  as  phenol-sulphuric  acid ; 
the  oxy-acids  pass  off  unaltered  with  the  urine. 

The  carbohydrates,  like  the  albuminoids,  are  also  subject  to 
bacterial  decomposition.  At  the  present  time  we  recognise  a  large 
number  of  bacteria,  which  through  fermentative  action  may  on  one 
hand  convert  starches  into  sugars,  and  on  the  other  cause  these 
very  sugars  to  ferment.  For  example,  the  bacillus  subtilis  and  the 
spirillum  of  cheese  are  both  capable  of  converting  starch  into  sugar ; 
but  further  long-continued  action  of  the  subtilis  on  this  sugar 
results,  according  to  van  den  Yelden,  in  fermentative  production  of 
lactic,  butyric,  and  succinic  acids. "  Some  bacteria  and  yeasts  can 
produce  invertin,  etc. ;  others,  again,  such  as  the  bacillus  butyricus, 
convert  lactic  acid  into  butyric  acid.  As  final  products  of  carbo- 
hydrate fermentation  we  have  a  number  of  gases,  the  most  important 
of  which  are  carbon  dioxid,  hydrogen  and  marsh  gas. 

Cellulose  fermentation  results  mainly  from  the  action  of  certain 
bacteria  or  vibrios. 

Fats  are  capable  of  fermentation,  especially  when  in  the  form  of, 
fatty  acids,  but  the  special  organisms  as  well  as  the  different  steps 
of  the  process  are  entirely  unknown  to  us. 

[THE  GASES  OF  THE  INTESTINES 

The  gases  occurring  within  the  intestinal  tract  are  derived  from 
three  sources : 

1.  They  enter  the  bowel  from  the  stomach. 

2.  They  pass  from  the  blood  into  the  intestines  by  diffusion. 

3.  They  are  formed  within  the  intestinal  canal. 

Of  these  three  sources  the  third  is  by  far  the  most  important 
and  active. 

1.  The  gases  that  may  enter  the  bowel  from  the  stomach 
are : 

a.  Air  swallowed  during  or  independently  of  the  ingestion  of 
food  (oxygen  and  nitrogen). 

h.  Gases  contained  in  food,  beverages,  and  medicated  liquids. 
These  consist  mainly  of  carbonic  acid,  but  small  qaantities  of  other 
gases  may  be  introduced  with  the  mineral  waters  (e.  g.,  sulphuretted 
hydrogen  in  sulphur  waters,  etc.). 

c.  Gases  originating  within  the  stomach.  These  are  partly 
absorbed,  partly  escape  from  the  body  through  eructations,  but  a 
certain  portion  passes  into  the  intestines.     In  the  early  stages  of 


PHYSIOLOGICAL  AND  PHYSIOLOGICO-CHEMICAL  EEMARKS     4:7 

normal  gastric  digestion,  micro-organisms  swallowed  with  the  food 
cause  some  fermentation  of  the  stomach  contents  with  a  result- 
ing formation  of  carbonic-acid  gas  and  hydrogen.  According  to 
Miller,^^  this  fermentation  ceases  as  soon  as  a  large  amount  of  hydro- 
chloric acid  has  been  produced.  Schierbeck  ^  has  demonstrated 
that  during  digestion  carbonic-acid  gas  is  produced  by  the  secreting 
cells  of  the  gastric  wall.  Strauss  ^^  and  Rosenheim  ^^  found  ammo- 
nia present  in  very  small  amounts. 

Under  pathological  conditions  (stagnation  with  or  without  the 
presence  of  hydrochloric  acid,  abscess  of  the  wall,  ulcerating  carci- 
noma, etc.),  in  addition  to  the  above-mentioned  two  gases,  hydro- 
gen, sulphuretted  hydrogen,  ammonia,  marsh  gas,  and  other  hydro- 
carbons may  be  produced.  It  is  but  natural  to  assume  that  with  a 
patulous  pylorus  and  fair  or  good  gastric  motility  these  abnormal 
gases  may  enter  the  intestines. 

2.  Bunge  ^  states  that  nitrogen,  and  l^othnageP^  that  carbonic- 
acid  gas,  enter  the  intestinal  canal  by  diffusion  from  the  blood. 

3.  Throughout  the  entire  intestinal  canal  gases  are  formed  from 
digestive  fermentation  and  bacterial  decomposition  of  the  food ;  in 
the  uppermost  portion  of  the  small  intestine,  from  the  action  of  acid 
gastric  chyme  and  of  the  free  acids  of  the  fats  upon  the  alkaline 
intestinal  and  pancreatic  juices.  The  amount  and  kind  of  gas 
formed  vary  according  to  the  diet  and  the  segment  of  bowel  in 
question.  Gas  formation  is  most  rapid  wherever  active  fermentative 
changes  occur — i.  e.,  in  the  upper  segments  of  the  small  intestine. 
Accordingly,  less  gas  is  produced  in  the  lower  portion  of  the  small 
intestine  and  very  little  in  the  large  bowel.  In  the  large  intestine 
gas  formation  has  almost  or  entirely  ceased,  and  putrefactive  decom- 
position and  inspissation  of  the  fseces  take  place. 

From  the  decomposition  of  the  alkaline  carbonates  of  the  intes- 
tinal juices  by  the  gastric  chyme  and  fatty  acids  in  the  uppermost 
portion  of  the  small  intestine  carbonic-acid  gas  is  formed.  After 
the  acids  have  been  neutralized,  intestinal  fermentation  and  decom- 
position begin. 

Of  the  solid  food  stuffs,  the  carhoJiydrates  yield  hydrogen,  car- 
bonic-acid gas,  and  a  small  quantity  of  marsh  gas,  varying  propor- 
tionately to  the  digestibility  of  the  carbohydrates.  Starchy  foods 
result  in  the  formation  of  but  very  little  marsh  gas,  while,  as  we 
know  from  the  experiments  and  investigations  of  Huge,*'  Tappei- 
ner,^^  and  Planer,^^  those  rich  in  cellulose  yield  more  marsh  gas  than 
any  other  variety  of  food.    Since  cellulose  is  not  altered  by  the  gas- 


48  DISEASES  OP  THE  INTESTINES 

tro-intestinal  secretions  of  man,  tlie  formation  of  marsh  gas  is  no 
doubt  due  to  bacterial  action. 

The  gases  that  result  from  the  digestion  and  decomposition  of 
proteid  material  are  formed  more  slowly  than  those  from  the  car- 
bohydrates. These  ai-e  hydrogen,  carbonic  acid,  marsh  gas,  ammo- 
nia, sulphuretted  hydrogen,  and,  according  to  Lehmann,  Hagemann, 
and  Zuntz,^^  nitrogen  under  certain  specific  conditions. 

As  already  mentioned,  the  fats,  by  the  action  of  their  fatty 
acids  upon  the  alkaline  intestinal  juices,  produce  carbonic-acid  gas. 

Considering  the  large  quantity  of  gases  normally  present  in  the 
intestine*  and  the  comparatively  small  amount  passed  as  flatus, 
their  absorption  must  be  a  very  active  one.  Eegnault  and  Eei- 
sert,^*  Tacke,^^  Zuntz,^^  and  others,  have  demonstrated  the  pres- 
ence of  marsh  gas  and  other  intestinal  gases  in  the  expired  air. 

Under  pathological  conditions  the  quantity  and  composition  of 
gases  in  a  given  segment  will  vary  from  the  normal.  It  will  depend 
upon  the  nature  of  the  contents  (amount  of  fermentative  material 
and  of  fermenting  agents — i.  e.,  bacteria,  moulds  and  yeasts),  the 
motility  of  the  bowels,  and  the  condition  of  the  circulation. 

In  sluggishness  or  total  arrest  of  the  contents  (e.  g.,  atony, 
paralysis,  obstruction,  occlusion,  etc.)  there  will  at  first  be  the  prod- 
ucts of  fermentation,  later  those  of  putrefactive  decomposition. 
By  his  experiments  Kader^^  showed  that  excessive  formation  of  gas 
within  the  intestinal  lumen  was  largely  dependent  upon  the  circula- 
tion in  the  mesentery.  In  those  experiments  in  which  the  mesen- 
tery was  ligatured,  marked  meteorism  developed  ;  in  those  in  which 
the  gut  alone  was  tied,  very  little  gas  developed,  (See  also  page  363 
of  this  work.) 

Certain  catarrhs,  by  offering  conditions  favourable  to  bacterial 
and  fungoid  growth,  favour  the  increase  of  gases  (l^othnageP^). 
The  same  holds  true  also  for  ulcerative  and  sloughing  conditions 
(carcinoma,  dysentery,  abscess,  gangrene,  etc.). 

On  the  other  hand,  in  abnormally  rapid  peristalsis  the  contents 
pass  so  quickly  through  the  intestine  that  only  easily  assimilated 
food  stuffs  are  decomposed.  The  starches  and  sugars  and  carbon- 
ated beverages  yield  gaseous  products  within  the  body ;  the  more 
resistant  carbohydrates,  the  fats,  the  proteids,  connective  tissues, 

*  [A  faint  idea  of  the  active  formation  that  goes  on  may  be  gained  by  mixing  a 
small  amount  of  fresh  faeces  (about  5.0  grams)  with  a^  little  water,  placing  the 
mixture  in  any  kind  of  a  fermentation  tube,  and  allowing  the  tube  to  remain  for  a 
short  time  in  an  incubator  at  37°  C. — Te.] 


PHYSIOLOGICAL  AND   PHYSIOLOGICO-CHEMICAL  REMARKS     49 

and  cellulose  pass  out  very  slightly  or  not  at  all  altered.  Hydrogen 
and  carbonic-acid  gas  are  mainly  formed  ;  the  fseces  are  often  passed 
in  a  state  of  active  starchy  and  saccharin  fermentation — Te.] 


LITERATURE 

1.  Grützner.     Pflüger's  Archiv,  Bd.  vii.  S.  358. 

3.  Hoppe- Seyler.     Physiolog.  Chemie,  Berlin,  1877-'81,  S.  374. 

3.  Bunge.     Lehrbuch  der  physiologischen  u.  pathologischen  Chemie,  Leipzig, 

1887,  S.  183. 

4.  Demant.     Virchow's  Archiv,  Bd.  Ixxv,  S.  419. 

5.  Brown  u.  Heron.     Annal.  Chem.  und  Pharm.,  1880,  Bd.  cciv,  S.  338. 

6.  K.  B.  Lehmann.     Arch,  für  die  gesammte  Physiologie,  Bd.  xxxiii,  S.  180. 

7.  Turby  and  Manning.     Centralblatt  f.  die  medicin.  Wissenschaften,  1892, 

ö.  945. 

8.  Miura.     Zeitschr.  f.  Biologie,  Bd.  xxxii,  S.  366-387. 

9.  Röhmann  u.  Lappe.     Berichte  d.  deutsch,  chem.  Gesellschaft,  Bd.  xxviii,  S, 

3,506  u.  3,507. 

10.  Frick.     Arch.  f.  wissensch.  u.  prakt.  Thierheilkunde,  Bd.  ix,  S.  148. 

11.  EUenberger  u.  Hofmeister.     Ibid.,  Bd.  x,  S.  437. 
13.  Wenz.     Zeitschr.  f.  Biologie,  N.  F.,  Bd.  iv,  1886. 

13.  C.  Schmidt.     Annal  d.  Chemie,  Bd.  xcii,  1854,  S.  34. 

14.  Zawadsky.     Centralbl.  f.  Physiologie,  1891,  Bd.  v. 

15.  Herter.     Zeitschr.  f.  physiolog.  Chemie,  Bd.  iv,  1880,  S.  100. 

16.  Podolinski.     Pflüger's  Archiv,  Bd.  x,  1875,  S.  557  u.  Bd.  xii,  1876,  S.  433. 

17.  S.  G.  Hedin.     Du  Bois-Reymond's  Archiv,  1891,  S.  373-378. 

18.  R.  Neumeister.     Zeitschr.  f.   Biologie,  N.  F.,  Bd.  viii,  1890  ;  and  Winter- 

nitz,  Zeitschr.  f.  physiolog.  Chemie,  Bd.  xvi,  1893,  S.  463. 

19.  Maly.     Jahresbericht,  Bd.  ix,  S.  334. 

30.  Boas.     Zeitschr.  f.  klin.  Medicin,  Bd.  xvii,  Heft  1  u.  3,  1890. 

31.  Musculus  u.  Gruber.     Zeitschr.  f.  physiolog.  Chemie,  Bd.  ii,  1878,  S.  177. 
33.  von  Mering.     Zeitschr.  f.  physiolog.  Chemie,  Bd.  v,  1881,  S.  185. 

33.  Nencki.     Arch.  f.   experiment.   Pathologie  u.  Pharmakologie,  Bd.   xx,   S. 

367. 
24.  Boas.     Deutsch,  med.  Wochenschr.,  1891,  No.  38. 

35.  Baas.     Zeitschr.  f.  physiol.  Chemie,  Bd.  xiv,  S.  416. 

36.  Voit.      lieber  die  Bedeutung  der  Galle  f.  die  Aufnahme  der  Nahrungs- 

mittel im  Darmcanal.  Festschrift,  München,  1883. 
27.  Röhmann.  Pflüger's  Archiv,  1883,  Bd.  xxix,  S.  509. 
38.  Neumeister.     Lehrbuch  der  physiolog.  Chemie,  1893,  Theil  i. 

29.  Heidenhain.     Pflüger's  Archiv,  1888,  Bd.  xliii,  S.  91. 

30.  Braam-Houkgeest.     Pflüger's  Archiv,  Bd.  vii,  1872,  S.  366. 

31.  Nothnagel.     Beiträge  zur  Physiologie  u.   Pathologie  des   Darms,  Berlin, 

1884. 

32.  Grützner.     Deutsch,  med.  Wochenschr.,  1894,  No.  48. 

33.  Christomanos.     Wiener  klin.  Wochenschr.,  1895,  Nos.  12  and  13. 

34.  Dauber.     Deutsch,  med.  Wochenschr.,  1895,  No.  34. 


50  DISEASES   OF   THE  INTESTINES 

35.  Wendt.     Munch,  med.  Wochenschr.,  1896,  No.  19. 

36.  Swiezynski.     Deutsch,  med.  Wochenschr.,  1895,  No.  32. 

87.  Riegel.     Die  Erkrankungen  des  Magens,  Wien,  1896,  S.  246. 

38.  J.  Pal.  Wiener  klin.  Wochenschr.,  1895,  Nos.  29  and  30. 

39.  J.  Pal.     Ibid.,  1897,  No.  2. 

40.  Bechterew  u.  Mislawski.     Arch.   f.  Anat.   u.   Physiol.,   1889,  Supplement- 

band. 

41.  Fellner.     Oesterr.  med.   Jahrbücher,   1883,  S.  571  ;  and  Pflüger's  Archiv, 

Bd.  Ivi,  1894. 

42.  L.  Exner.     Pflüger's  Archiv,  Bd.  xxxix,  1884,  S.  310. 

43.  J.  Pal.     Wiener  klin.  Wochenschr.,  1895,  Nos.  39  and  40. 

44.  Plosz.  u.  Gyergyay.     Pflüger's  Archiv,  Bd.  vi. 

45.  Hofmeister.     Zeitschr.  f.  physiol.  Chemie,  Bd.  v. 

46.  Ibid.     Archiv  für  experiment.   Pathol,   u.    Pharmakol.,  Bd.  xix,  xx  und 

xxii. 

47.  Abelmann.     lieber  die  Ausnützung  der  Nahrungsstoffe  nach  Pancreasex- 

tirpation.     Inaug. -Dissert.,  Dorpat,  1890. 

48.  Sandmeyer.     Zeitschr.  f.  Biologie,  1895,  Bd.  xxxi,  S.  12. 

49.  von  Mering.     Du  Bois-Reymond's  Archiv  f.  Physiologie,  1877,  S.  379. 

50.  I.  Munk  u.  Rosenstein.     Virchow's  Archiv,  1891,  Bd.  cxxiii,  S.  230. 

51.  Ginsberg.     Pflüger's  Archiv,  Bd.  xliv,  S.  306. 

52.  Cited  from  Maly's  Jahresb.  f.  Thierchemie,  Bd.  xvii,  S.  134. 

53.  Fr.  Müller.     Zeitschr.  f.  klin.  Medicin,  1887,  Bd.  xii. 

54.  Zawarykin.     Pflüger's  Archiv,  1883,  Bd.  xxxi  ;  1885,  Bd.  xxxv. 

55.  Wiedersheim.    Freiburger  Festschrift  zum  56.     Naturforscherversammlung, 

1887. 

56.  I.  Munk.     Virchow's  Archiv,  Bd.  Ixxx. 

57.  von  Walther.     Du  Bois-Reymond's  Archiv,  1890,  S.  329. 

58.  Perewozisnkoff.     Centralbl.  f.  d.  med.  Wissenschaften,  1876,  No.  47. 

59.  Will.     Pflüger's  Archiv,  Bd.  xx,  1879,  S.  255. 

GG.  C.  A.  Ewald.     Du  Bois-Reymond's  Archiv,  1883,  Supplementband,  S.  302. 

61.  I.  Munk.     Virchow's  Archiv,  Bd.  Ixxx,  S.  10  ;  Bd.  xcv,  S.  407. 

62.  Arnschink.     Zeitschr.  für  Biologie,  Bd.  xxvi,  S.  434. 

63.  Rubner.     Ibid.,  Bd.  xv,  S.  115  et  seq. 

64.  Fleischer.     Lehrbuch  d.  inneren  Medicin,  Bd.  ii,  Theil  2,  S.  1,077. 

65.  Teichmann.     Mikroskop.  Beiträge  zur  Lelire  von  d.  Fettresorption,  luaug.- 

Dissert.,  Breslau,  1891. 

66.  Eichhorst.     Pflüger's  Archiv,  1871,  S.  570. 

67.  Voit  u.  Bauer.     Zeitschr.  f.  Biologie,  Bd.  v,  1869. 

68.  Leube.     Deutsch.  Archiv  f.  klin.  Medicin,  1872.  Bd.  x. 

69.  Ewald.     Zeitschr.  f.  klin.  Medicin,  1887,  Bd.  xii. 

70.  Huber.     Deutsch.  Archiv  f.  klin.  Medicin,  1891,  Bd.  xlvii. 

71.  Kohlenberger.     Münch.  med.  Wochenschr.,  1896,  No.  47. 

72.  Kobert.     Deutsch,  med.  Wochenschr.  1894,  No.  47. 

73.  Deucher.     Deutsch.  Archiv  f.  klin.  Medicin,  1897,  Bd.  Iviii,  S.  21G. 

74.  Hermann.     Pflüger's  Archiv,  1890,  Bd.  xlvi,  S.  93. 

75.  Fr.  Müller.     Virchow's  Archiv,  1893,  Bd.  cxxxi,  Supplementheft. 

76.  von  Noorden  u.  Belgardt.     Berliner  klin.  Wochenschr.,  1894,  No.  10. 


PHYSIOLOGICAL  AND  PHYSIOLOGICO-CHEMICAL  REMAKKS     51 

77.  G.  Honigmann.     Archiv  f.  Verdauugskrankheiten,  1896,  Bd.  ii,  S.  296. 

78.  Voit.     Zeitschr.  f.  Biologie,  1889,  Bd.  xxv,  S.  264. 

79.  Woodward.     Med.  and  Surg.  Report  of  the  War  of  the  Rebellion,  vol.  i. 

Part  2,  1879. 

80.  Heidenhain.     Pflüger's  Archiv,  Bd.  x,  S.  557. 

81.  Bernstein.     Arbeiten  aus  der  physiolog.  Anstalt  zur  Leipzig,  1869. 

82.  Rossbach.     Deutsch.  Archiv  f.  klin.  Medicin,  Bd.  xlvi,  S.  296. 

83.  Nencki,  Macfadyen  u.    Sieber.      Archiv  f.  expei-imentelle  Pathologie  u. 

Pharmakologie,  Bd.  xxviii,  S.  311-350. 
[84.  Miller.     Deutsch,  med.  Wochenschrift,  1885,  No.  49.] 
[85.  Schierbeck.     Scand.  Arch,  of  Physiol.,  vols,  ii  and  iv.    Quoted  from  Ham- 

marsten's  Lehrb.  d.  physiolog.  Chemie.,  1895,  3te  Aufl.,  S.  246.] 
[86.  Strauss.     Berl.  klin.  Wochenschr.,  1893,  No.  17.] 
[87.  Rosenheim.     Centralbl.  f.  klin.  Medicin,  1892,  No.  39] 
[88.  Bunge.     Lehrbuch,  etc.,  S.  268.] 
[89.  Nothnagel.     Darm  u.  Peritoneum,  1898,  S.  64.] 

[90.  Ruge.   Sitzungsber.d.  Wiener  Akademie  d.  Wissenschaften,  1861,  Bd.  xliv.] 
[91.  Tappeiner.     Zeitschr.  f.  Biologie,  1893,  Bd.  xix,  S.  223.] 
[92.  Planer.    Sitzungsber.  d.  Wiener  Akad.  d.  Wissensch.,  1860,  Bd.  Ixii,  S.  307.] 
[93.  Hagemann,  Lehmann  u.  Zuntz.     Landwirthschaftliche  Jahrbücher,  1894, 

S.  125.] 
[94.  Regnault  u.  Reisert.     Quoted  from  Nothnagel,  loc.  cit.,  p.  64.] 
[95.  Tacke.     lieber  d.  Bedeutung  d.  brennbaren  Gase  im  mensclilichen  Orga- 
nismus.    Inaug.-Dissert.,  Berlin,  1889.] 
[96.  Kader.     Deutsch.  Archiv  f.  Chirurgie,  1891,  Bd.  xlii,  S.  57,  etc.] 


DISEASES   OF  THE   Ü^TESTH^TES 


PART  I 
GENERAL     DIVISION 


CHAPTER    III 

THE  HI8T0BY 

In  diseases  of  the  intestines  the  history  is  of  almost  greater 
importance  than  in  gastric  affections.  In  the  latter  the  diseased  area 
is  very  limited ;  in  the  former  it  is  far  more  extensive.  Whereas 
in  gastric  disease  we  can  determine  the  condition  through  physical 
and  functional  examinations  alone,  in  intestinal  diseases  we  are  com- 
pelled to  rely  mainly,  sometimes  even  entirely,  upon  the  statements 
of  our  patients.  Too  much  care,  therefore,  can  not  be  expended  in 
obtaining  as  complete  a  history  as  possible. 

ISTaturally  here,  as  elsewhere,  our  first  inquiry  should  not  be  con- 
cerned with  the  local  disturbances,  but  with  the  patient's  previous 
general  health.  Hereditary  tendencies  must  be  taken  into  account. 
Our  view  of  a  case  may  be  radically  influenced  by  the  existence  of 
special  dyscrasias,  as  syphilis,  tuberculosis,  etc.,  or  by  learning  of 
the  habitual  employment  of  poisons  which  we  know  from  experience 
to  be  injurious  to  the  gastro-intestinal  tract  (alcohol,  tobacco,  lead, 
mercury,  tin,  zinc,  argenic,  antimony,  etc.).  Special  interest  is 
imparted  to  a  case  by  a  previous  history  of  infectious  diseases,  par- 
ticularly such  as  have  local  manifestations  in  the  intestines — e.  g., 
typhoid,  cholera,  dysentery,  intestinal  tuberculosis,  etc.  Owing  to  its 
etiological  relations  to  cancer,  a  traumatism  received  prior  to  the 
development  of  a  disease  merits  special  consideration.  In  the 
female,  the  sexual  apparatus  should  receive  due  attention,  since  it  is 
frequently  a  cause  of  intestinal  troubles.  "We  should  inquire  par- 
ticularly into  the  menstrual  condition,  childbirths,  previous  opera- 
tions, as  well  as  regarding  any  special  symptoms  the  patient  may 
have  noticed  (leucorrhoea,  menorrhagia,  metrorrhagia,  pains,  pres- 
sure, etc.).  In  men,  too,  there  is  frequently  a  direct  connection 
between  diseases  of  the  sexual  organs  and  those  of  the  intestines,  so 
that  careful  inquiry  ought  never  to  be  omitted.  I  need  but  recall 
diseases  of  the  prostate  gland.  It  is  only  after  having  thus  obtained 
a  clear  and  complete  oversight  of  any  other  local  or  general  affec- 

55 


56  DISEASES   OF  THE  INTESTINES 

tions,  which  at  first  seem  to  have  no  cpnnection  with  the  present 
symptoms,  that  we  ought  to  inquire  into  the  details  of  the  affec- 
tion in  question. 

Regarding  those  points  referable  to  gastric  digestion,  the  reader 
is  referred  to  Pai"t  I  (general  section)  of  my  work  on  Diseases  of 
the  Stomach.  There  the  most  important  facts  bearing  upon  intes- 
tinal disturbances  are  discussed. 

Whenever  there  is  a  suspicion  of  intestinal  disease  a  most 
thorough  local  examination  is  indispensable.  We  may  begin  with 
the  symptoms  complained  of  by  the  patient,  or,  preferably,  we  can 
pursue  a  definite  plan  of  inquiry  which  shall  include  all  the  anam- 
nestic data  that  can  be  gained  from  the  history  of  a  case. 

The  following  scheme  has  been  of  great  service  to  me  for  many 
years : 

1.    Pai:s"  along  the  Course  or  the  Intestines 

(a)  Seat  of  the  pain. 

(5)  Origin  of  the  pain  ;  acute  or  chronic  ;  paroxysmal. 

(c)  Character  of  the  pain ;  burning,  boring,  stabbing,  tearing, 
colicky,  lancinating. 

{d)  Duration  of  the  pain. 

(e)  Kelation  of  pain  to  digestion ;  how  influenced,  if  at  all,  by 
quantity  and  variety  of  food. 

(y)  Does  the  attack  of  pain  cease  with  the  passage  of  wind  or 
of  stool ;  or  have  these  no  influence  upon  the  pain  ? 

(g)  How  do  rest  and  motion  affect  the  pain  ? 

{h)  What  is  the  effect  of  manual  pressure  upon  the  painful 
area? 

As  a  rule,  the  statements  of  the  patient  regarding  the  seat  of  the 
pain  are  not  conclusive  for  the  physician  ;  for  it  requires  very  good 
powers  of  observation  to  properly  describe  to  the  physician  the 
point  of  origin  of  the  pain,  its  extent,  etc.  Should  the  pain  become 
intense,  the  patients  naturally  think  less  of  its  exact  situation  than 
they  do  of  its  severity.  Pain  in  one  region  of  the  intestines  alone — 
that  of  the  vermiform  appendix  or  of  the  caecum — is  so  very  char- 
acteristic that  even  the  layman  can  localize  it  quite  well.  Its  distinct 
localization  indeed  differentiates  CEecal  from  similar  pains.  If  the 
patient  tells  us  that  the  pain  is  continuous,  that  it  increases  upon 
motion  and  diminishes  with  rest,  that  the  painful  area  is  sensi- 
tive to  pressure,  that  the  attack  began  with  fever,  and  perhaps 
that  similar  attacks  have  already  occurred,  the  diagnosis  of  appen- 


THE   HISTORY  5Y 

dicitis  or  typhlitis  is  almost  certain.  Similarly,  at  least  in  well- 
developed  cases  of  round  ulcer  of  the  duodenum,  we  find  a  strictly 
circumscribed  area  of  tenderness.*  This  pain  is  characterized  by 
its  situation  in  the  prolongation  of  the  right  parasternal  line  some- 
what below  the  gall  bladder.  Usually  the  pain  begins  three  or 
four  hours  after  a  meal,  and  rarely  or  never  radiates  toward  the 
back ;  it  is  worse  after  the  ingestion  of  solid  food  and  less  after 
a  fluid  diet ;  rest  diminishes  and  bodily  movements  increase  it.  If 
the  patient  be  of  the  male  sex,  and  his  statements  coincide  with 
what  has  just  been  said,  there  is  at  least  a  well-grounded  suspicion 
of  duodenal  ulcer,  and  we  should  keep  this  in  view  in  making  our 
examination. 

Typical  cases  with  pronounced  symptoms,  such  as  are  described 
in  text-books,  are  very  rare.  These  are  the  classical  cases  which 
every  physician  knows.  In  the  great  majority  of  cases  a  probable 
diagnosis  of  the  real  condition  can  only  be  arrived  at  after  repeated 
questions  as  to  the  location,  character,  and  intensity  of  the  pain.  If 
the  patient  be  seen  during  his  attack  of  pain,  we  may  sometimes 
come  to  a  rapid  conclusion  concerning  the  nature  of  the  case  from 
the  general  behaviour,  the  facial  expression,  the  character  of  the 
patient's  crying  or  groaning,  etc.  For  exam]3le,  the  painfully 
anxious  and  depressed  facial  expression  of  peritonitis,  with  the 
increased  respirations,  the  rapid  small  pulse  contrasting  with  a  high 
temperature,  the  instinctive  dread  of  the  slightest  contact  and  of 
pressure  even  of  the  bedclothes,  are  so  characteristic  that  an  expe- 
rienced physician,  simply  from  hearing  such  symptoms  described, 
will  at  once  recognise  a  serious  condition,  although  he  may  not  be 
certain  as  to  the  exact  diagnosis. 

The  pain  accompanying  acute  or  chronic  intestinal  stenosis  or 
occlusions  is  not  so  well  characterized.  Treves^  makes  the  general 
statement  that  the  pain  of  complete  obstruction  is  constant  (although 
subject  to  exacerbations),  while  that  of  partial  obsti'uction  is  inter- 
mittent, alternating  with  intervals  of  freedom  from  pain.  My  own 
views  coincide  fully  with  Treves's,  although,  as  he  himself  admits, 
exceptions  to  the  rule  occur.  In  other  respects  the  pain  which 
accompanies  intestinal  occlusion  and  stenosis  offers  nothing  diag- 
nostic. From  this,  however,  it  should  not  be  inferred  that  the 
pain  of  ileus  is  like  that  of  volvulus  of  the  sigmoid,  or  like  that  of 


*  Round  ulcers  of  the  jejunum  or  the  ileum  are  very  rare,  and,  as  a  rule,  can  not 

be  diagnosticated. 


58  DISEASES   OF   THE   INTESTINES 

an  invagination  or  even  of  an  obstruction  caused  by  a  foreign  body, 
but  ratlier  that  it  is  difficult,  or  even  impossible,  to  make  use  of  these 
distinctions  in  the  differential  diagnosis.  We  shall  return  to  this 
point  in  the  special  part  of  this  work.  Similar  difficulties  are 
encountered  where  there  is  a  history  of  periodic  attacks  of  pain.  If 
a  long  interval  has  elapsed  between  the  time  of  the  last  attack  and 
of  our  examination,  the  statements  of  the  patient  will  be  uncertain, 
and  for  the  most  part  guesswork.  In  such  a  case  we  must  seek  to 
establish  a  connection  between  the  paroxysms  of  pain  and  the  intes- 
tinal functions — viz.,  to  learn  if  obstinate  constipation  ordinarily 
precedes  the  attack,  if  the  abdomen  is  full  and  distended,  and,  finally, 
if  the  passage  of  gas  from  above  or  from  below,  or  of  a  copious  stool, 
causes  the  paroxysms  to  cease.  These  phenomena  very  probably 
point  to  flatulent  colic,  although  they  may  also  occur  with  chronic 
intestinal  stenosis.  Even  in  the  absence  of  constipation,  more  or 
less  severe  colicky  pains  may  also  be  caused  by  decomposed  food 
which  remains  for  some  time  within  the  intestinal  canal.  Even 
though  we  may  not  at  first  discover  any  etiological  factor,  obstinate 
constipation  complicating  intestinal  colic  should  lead  us  to  think  of 
lead  colic  (colica  saturnica).  Our  inabihty  to  establish  any  connec- 
tion between  the  paroxysms  of  pain  and  the  gastro-intestinal  func- 
tions by  no  means  justifies  our  declaring  the  pains  purely  "nervous," 
and  thereupon,  as  careless  examiners  or  novices  so  frequently  do, 
construing  a  picture  of  hysteria  or  of  neurasthenia  from  answers 
which  the  patient  makes  to'  leading  questions.  "We  should  first 
examine  those  other  organs  which  frequently  cause  paroxysms  of 
pain — above  all,  the  liver,  kidney,  pancreas  (?),  and  the  bladder — 
since  stone  colics  occur  in  these  organs.  In  women,  the  uterus, 
adnexa,  etc.,  must  be  examined. 

One  who  knows  from  experience  that  severe  gastralgias  and 
enteralgias  may  be  caused  from  very  small  supraumbilical  or  crural 
hernise,  and  by  apparently  insignificant  prseperitoneal  lipomata,  will 
be  very  careful  before  making  the  diagnosis  of  "  nervous  intestinal 
pain."  At  all  events,  I  wish  to  state  here  that  "  enteralgias,"  as 
purely  functional  neuroses,  occur  much  more  rarely  than,  for  exam- 
ple, gastralgias.  (For  further  details,  see  chapter  on  Intestinal 
ISTeuroses  in  the  special  part  of  this  work.)  It  is  scarcely  necessary 
to  mention  that  whenever  we  have  a  well-grounded  suspicion  of 
enteralgia  the  central  nervous  system  should  be  most  carefully 
examined  (crises  enteriques  of  tabes,  of  myelitis,  and  of  progressive 
paralysis). 


THE  HISTORY  59 

The  individual  causes  which  may  occasionally  give  rise  to  intestinal  pain 
are  too  numerous  to  mention.  I  simply  wish  to  state  that  we  should  remember 
that  this  pain  may  be  due  to  swallowed  foreign  bodies  (needles,  fish  bones),  to 
entozoa,*  or  more  so  even  to  poisonous  metabolic  products  such  as  occur,  for 
example,  after  death,  or  disease  of  tapeworms  and  other  intestinal  parasites. 
Lastly,  we  must  consider  the  possibility  of  nicotin  poisoning. 

It  is  of  great  diagnostic  importance  to  give  a  careful  description 
of  rectal  pain.  The  jiature  of  these  pains  varies  considerably  with 
their  cause.  When  limited  to  the  rectum,  the  pains  may  be  press- 
ing, boring,  burning,  or  even  colicky  in  character.  They  may  be 
continuous,  or  may  occur  for  a  short  time  only,  before,  after,  or 
during  a  fsecal  evacuation.  These  rectal  pains  may  be  caused  by  a 
simple  coprostasis  in  the  ampulla  recti  (the  latter  sometimes  acquir- 
ing enormous  dimensions).  They  may  be  due  to  haemorrhoids,  to 
fissures  or  fistulse,  to  rectal  ulcers  (tuberculosis,  fsecal  ulcers,  degen- 
erated syphiloma),  or,  finally,  to  stenoses  of  the  rectum  from  tumours 
or  cicatricial  contractions.  It  is  best  not  to  spend  too  much  time 
upon  the  consideration  of  these  different  possibilities.  In  most  cases 
we  can  at  once  discover  the  condition  present  by  digital  examina- 
tion, aided  perhaps  by  further  examination  with  the  speculum. 

Anal  pains  may  likewise  be  due  to  strangulated  haemorrhoids,  to 
fissures  of  the  mucous  membrane,  to  fistulse,  or  to  periproctitis. 
Here,  too,  direct  inspection  is  the  surest  means  of  ascertaining  the 
cause  of  the  symptoms. 

2.  Meteoeism,  Tympanites 

(a)  Acute,  chronic,  or  paroxysmal. 
{b)  Local  or  general. 

Meteorism  is  a  symptom  which,  when  developed  to  a  marked 
degree,  may  be  complained  of  by  the  patient.  To  be  sure,  a  so- 
called  "  meteorism  "  not  infrequently  turns  out  to  be  an  ascites. 
Meteorism  is  of  diagnostic  significance  only  when  taken  in  connec- 
tion with  the  rest  of  the  symptoms.  It  may  be  caused  solely  by  the 
ingestion  of  food  abnormally  rich  in  gases,  or  which  forms  gases 
(carbonated  liquids,  sauerkraut,  the  so-called  "  bloating  substances  "). 
The  statement  that  meteorism  has  suddenly  occurred  in  connection 

*  Recently  I  have  observed  a  case  referred  to  me  by  Dr.  Perel,  of  Odessa,  in 
which  very  severe  and  constant  intestinal  pains  were  caused  by  the  taenia  nana. 
As  is  well  known,  the  pains  caused  by  the  taenia  solium  or  mediocanellata  are  mild, 
or  altogether  wanting. 


60  DISEASES   OP   THE   INTESTINES 

with  constipation  is  important,  for  this  association  maj  speak  for  a 
simple  coprostasis ;  we  may,  however,  have  to  deal  with  retention 
of  gases  in  a  commencing  obstruction,  an  incarcerated  hernia,  an 
invagination — in  short,  with  any  condition  which  can  obstruct  the 
downward  passage  of  gases,  or  even  with  an  acute  diffused  or  cir- 
cumscribed peritonitis.  It  may  even  be  one  of  those  singular 
gaseous  distentions  occurring  in  hysterical  persons,  which  may 
prove  a  souröe  of  great  anxiety  and  of  error  to  the  novice. 

Before  beginning  the  objective  examination,  close  questioning 
may  enable  us  to  form  a  correct  idea  of  the  true  condition  present. 

Chronic  meteorism,  more  or  less  circumscribed,  is  also  a  symp- 
tom of  manifold  significance  which  can  not  be  correctly  valued 
without  thorough  investigation.  Where  the  meteorism  is  circum- 
scribed, we  must  think  of  adhesions,  or  of  stenosis,  from  tumours 
situated  either  within  the  intestines  or  external  to  them,  and  partly 
connected  with  other  abdominal  organs — in  women  especially  with 
the  genital  organs. 

3.  Constipation 

{a)  Acute,  chronic,  habitual,  or  periodic. 

(5)   If  acute,  when  was  the  last  movement  ? 

(c)   If  chronic,  does  it  alternate  with  diarrhoea  ? 

{d)  Duration  of  the  entire  trouble. 

{e)  Are  the  movements  retarded,  or  spontaneous,  or  do  they 
occur  only  after  laxatives  ?  If  the  last,  what  is  the  nature 
of  the  laxative  ?     Are  enemata  employed  ? 

Constipation  may  at  times  be  a  harmless  condition ;  at  other 
times  it  may  be  extremely  severe  and  dangerous,  frequently  causing 
death.  The  first  question  which  presents  itself  is :  Have  we  to  do 
with  acute  constipation  in  a  case  in  which  up  to  the  present  time 
there  were  normal  movements  ?  Such  a  condition  may  naturally 
be  brought  about  by  various  causes — e.  g.,  sudden  change  in  habits 
of  life  or  in  climate,  errors  in  diet,  mental  excitement,  diarrhoeas 
lasting  for  days  and  weeks,  the  administration  of  opium,*  bismuth, 
tannin,  morphin  injections,  or  of  other  drugs  which  cause  temporary 
arrest  of  intestinal  peristalsis.     Intestinal  occlusion  or  stenosis  may 


*  For  a  long  time  I  have  had  under  observation  a  female  patient  who  has  suf- 
fered from  obstinate  constipation  since  an  attack  of  perityphlitis.  The  cause  of 
her  constipation  is  most  probably  the  use  of  large  doses  of  opium.  (C/.  further 
remarks  as  to  this  in  the  chapter  on  Perityphlitis,  Part  IT.) 


THE   HISTORY  Qi 

be  present,  or  the  constipation  may  be  an  accompanying  symptom 
of  an  acute  affection  of  the  central  nervous  system  (basilar  menin- 
gitis) or  an  acute  lead  colic.  Here,  again,  only  a  careful  general  as 
well  as  local  examination  can  demonstrate  the  true  underlying  con- 
dition.* 

Where  we  have  to  deal  with  a  case  of  chronic  habitual  constipa- 
tion, the  existence  of  a  functional  intestinal  weakness  (intestinal 
atony),  or  of  an  organic  condition,  will  come  into  question.  This, 
again,  can  only  be  determined  by  a  detailed  examination.  Where 
there  is  constipation  lasting  for  many  years  and  not  associated  with 
disturbances  of  the  general  bodily  conditions,  one  generally  thinks 
of  "  functional  intestinal  weakness  "  (atony)  or  of  intestinal  catarrh. 
It  should  never  be  forgotten,  however,  that  habitual  constipation 
and  chronic  enteritis  also  predispose  to  the  development  of  intes- 
tinal cancer  with  subsequent  stenosis  (see  chapter  on  Cancer).  Even 
at  the  present  day  the  view  so  often  expressed,  that  many  years'  dura- 
tion of  a  disease  speaks  against  cancer,  is  only  correct  when  greatly 
modified.  The  frequent  development  of  cancer  upon  a  coprostasis 
of  many  years'  duration  should  teach  us  to  be  more  cautious.  Fur- 
thermore, in  women  we  should  always  examine  for  some  genital 
disorder  as  a  cause  of  existing  constipation  (retroflexed  uterus,  dis- 
ease of  the  ovaries  or  of  the  appendages,  etc.).  Where  the  entire  clin- 
ical picture  is  unlike  malignant  disease,  an  exact  knowledge  of  the 
duration  and  the  previous  treatment  are  important.  Constipation 
is  sometimes  congenital  or  inherited  (intestinal  atony),  or  it  may  be 
acquired  during  earliest  childhood.  This  is  important  for  the  prog- 
nosis and  the  treatment  of  the  case.  A  knowledge  of  the  nature 
and  effect  of  the  various  therapeutic  measures  employed  is  essential 
for  the  proper  appreciation  of  the  diseased  condition.  The  j>oot'er 
the  reaction  of  the  intestines  to  laxative  measures,  the  more  difficult 
the  treatment,  and  vice  versa. 

Where  constipation  alternates  with  diarrhoea,  we  must  first  of  all 
decide  which  is  the  primary  or  dominating  condition.  It  is  by  no 
means  easy  for  a  patient  who  has  doctored  much,  and  who  has  alter- 
nated between  laxatives  and  astringents,  to  answer  this  question. 
To  appreciate  the  real  functional  disturbance,  it  is  best  for  the  pa- 
tient to  stop  all  medication  for  a  few  days.     Should  diarrhoea  regu- 

*  In  this  connection  it  might  be  remarked  that  regular  movements  of  the  bowels, 
or  even  diarrhceas,  do  not  at  all  exclude  intestinal  occlusion.  Cases  with  undoubted 
intestinal  obstruction  have  been  described  in  which  faecal  vomiting  as  well  as  the 
passage  of  wind  from  below,  or  even  fajcal  movements,  occurred. 


62  DISEASES   OF   THE   INTESTINES 

larlj  follow  constipation,  organic  stenosis  of  some  kind  in  some  part 
of  the  intestines,  or  else  an  intestinal  catarrh,  may  be  present.  Here, 
again,  without  a  most  careful  examination,  especially  of  the  rectum, 
it  is  absolutely  impossible  to  come  to  a  conclusion.  Finally,  should 
repeated  examinations  constantly  yield  negative  results,  the  ques- 
tion of  a  nervous  enteropathy  or  of  hysteria  may,  with  the  greatest 
reserve,  be  considered. 

4.     DiAEEHCEA 

{a)  Acute  or  chronic  ;  during  intervals  ? 

(b)  How  frequently  during  the  day  ? 

(c)  With  or  without  pain  ;  if  present,  its  character  and  situation. 
{d)  Does  constipation  follow  the  diarrhoea  ? 

A  sudden  attack  of  diarrhoea  may  result  from  a  simple  error  in 
diet,  or,  on  the  other  hand,  may  initiate  a  severe,  acute,  infectious 
disease  (typhoid,  dysentery,  cholera  nostras,  and  asiatica,  ptomain 
poisoning  from  decayed  meats,  etc.).  In  these  cases  the  disease 
presents  a  number  of  other  symptoms,  which,  together  with  the 
objective  examination,  sooner  or  later  clear  up  the  diagnosis.  We 
may,  however,  have  to  deal  with  one  of  those  frequent  cases  of 
infectious  enteritis  which  originate  especially  during  the  summer 
months,  from  bacterial  or  other  direct  local  sources  (dyspeptic  diar- 
rhoea, ISTothnagel). 

Chronic  recurring  diarrhoea  occurs  as  a  symptom  of  organic 
intestinal  disease,  of  local  intestinal  neuroses  (i.  e.,  secretion  neuroses, 
reflex  neuroses  of  tabes  and  other  systemic  diseases,  crises  ente- 
riques),  or  of  nervous  enteropathies.  If  the  diarrhoea  is  a  symptom 
"of  the  first-named  affections,  it  may  be  due  to  catarrh,  atrophy, 
ulceration,  or  amyloid  disease  of  the  intestinal  mucous  membrane. 
In  stenoses  of  the  intestine  there  are  generally,  every  few  days, 
watery,  pasty,  or  partially  fluid,  partially  solid  stools.  Under  pre- 
disposing conditions,  patients  with  stenosing,  ulcerating  carcinoma 
of  the  ileum  may  have  continual  diarrhoeas,  usually  of  a  purulent 
character.  I  have  observed  and  performed  post-mortem  examina- 
tions on  two  such  cases  (for  particulars,  see  Part  II  of  this  work). 
Finally,  chronic  diarrhoeas  may  occur  as  a  symptom  of  nephritis 
(ursemic  diarrhoea),  of  the  uric-acid  diathesis,  of  congestion  in  the 
portal  system,  etc.  The  symptom  "  diarrhoea,"  therefore,  is  so 
closely  connected  with  apparently  widely  differing  conditions  that  a 
satisfactory  diagnosis  of  its  cause  and  nature  can  not  be  reached 
without  a  careful  general  and  local  examination. 


THE   HISTORY  63 

5.  Chaeactee  of  the  Evacijations 

{a)  Consistency,  quantity,  and  colour, 

{h)  Pathological  admixtures  (mucus,  fragments  of  membrane, 
blood,  pus,  tumour  detritus,  parasites). 

(c)  Odour  (feculent  or  putrid). 

In  most  cases  the  physician  should  not  be  satisfied  with  the 
description  of  the  stools  as  given  him  by  the  layman,  but  should 
inspect  them  himself,  and  eventually  examine  them  under  the 
microscope.  If  necessary,  a  chemical  examination  should  also  be 
made.  Where  the  patient's  statements  are  positive,  or  where  they 
can  not  be  personally  controlled,  the  descriptions  as  given  can  not 
be  entirely  ignored,  for  occasionally  the  statements  are  of  the  great- 
est importance.  Sometimes  a  careful  account  of  the  consistency 
and  calibre  of  the  stools  is  of  decisive  value  in  arriving  at  a  diag- 
nosis by  exclusion.  Thus,  persistent  cylindrical  stools  of  normal 
calibre  would  generally  exclude  a  stenosis  of  the  intestines. 

Conversely,  stools  of  an  abnormally  small  calibre  do  not  speak 
with  any  degree  of  certainty  for  a  stenosis  of  the  intestines ;  in 
this  case  the  diagnosis  must  rest  upon  the  presence  of  other  symp- 
toms. The  stools  may  be  pasty,  semisolid,  or  fluid  in  consistency. 
The  first  two  of  these  characteristics  may  be  present  in  the  normal 
individual ;  the  last  is  always  indicative  of  an  abnormal  condition 
and  calls  for  a  most  careful  examination.  Scybalous  stools  indicate 
a  long  retention  of  the  faeces  in  the  haustra  coli,  and  this  is  a  fre- 
quent cause  of  attacks  of  intestinal  colic  (spastic  contraction  of  the 
intestines). 

The  patient's  statement  of  the  quantity  of  faeces  passed  in 
twenty -four  hours  is  generally  correct.  I  say  generally,  because  I 
have  often  had  neurasthenics  declare  that  they  have  had  insufiicient 
evacuations,  although  they  actually  passed  large  quantities  of  faeces. 
In  many  cases  the  quantity  is  not  commensurate  with  the  amount 
of  food  ingested ;  this  may  be  due  to  the  kind  of  food  taken  (espe- 
cially meat),  or  to  deficient  peristalsis.  Probably  intestinal  absorp- 
tion is  increased  after  a  period  of  fasting,  so  that  even  normally 
in  the  first  few  hours  after  eating  again  the  amount  of  undigested 
matter  is  disproportionate  to  the  amount  of  food  ingested. 

The  colour  of  the  movements  may  vary  considerably  from  the 
normal.  The  patients  are  most  apt  to  notice  the  clay-coloured 
stools  that  occur  with  icterus,  or  sometimes  without  icterus  (see  sec- 
tion on  Faeces).     But  since  icterus  is  only  a  symptom,  the  diagnosis 


64  DISBASES  OF  THE  INTESTINES 

of  tlie  primary  trouble  is  impossible  without  further  knowledge  of 
the  cause  of  the  disease. 

The  pathological  admixtures  in  the  fseces  which  may  at  times 
be  seen  and  correctly  described  by  the  patients  are  mucus,  mucous 
membrane,  blood,  pus,  fragments  of  new  growths,  undigested  food 
remnants,  and  parasites. 

Where  imicus  is  present  in  large  quantities,  or  is  passed  alone, 
it  is  usually  noticed  by  observant  patients.  Sometimes  these  move- 
ments of  mucous  membranes  are  so  characteristically  described  that 
the  diagnosis — membranous  enteritis  (colica  mucosa) — is  readily 
made.  In  general  the  patient's  descrij)tion  very  seldom  yields  use- 
ful data. 

Blood  may  be  mixed  with  the  stools,  in  a  fresh  fluid  or  decom- 
posed state.  The  latter  lends  an  intensely  tarry  or  pitchy  appear- 
ance to  the  stool.  However,  the  description,  or  even  the  micro- 
scopical appearance,  is  decisive  only  in  a  very  few  and  these  other- 
wise absolutely  clear  cases  (see  section  on  Fseces).  It  is  important 
here  to  know  if  symptoms  of  severe  internal  hsBmorrhage  (collapse, 
syncope,  pallour  of  the  visible  mucous  membranes,  systolic  murmur 
at  the  apex  of  the  heart,  etc.)  accompany  the  intestinal  haemorrhage. 
The  darker  the  appearance  of  the  blood  the  more  correct  are  we 
in  assuming  that  the  bleeding  is  located  very  high  up  (stomach  or 
upper  portion  of  small  intestines).  Tar-coloured  blood  comes  only 
exceptionally  from  the  lower  portions  of  the  intestines.  Fluid  blood 
comes  mostly  (but  not  always)  from  the  large  intestine,  including 
the  rectum.  By  rectal  palpation,  or  by  use  of  the  speculum,  it  can 
frequently  be  determined  whether  the  latter  is  the  seat  of  the  bleed- 
ing or  not.  If  the  rectum  can  be  excluded,  various  diseased  pro- 
cesses may  come  up  for  consideration — acute  or  chronic  dysentery, 
fsecal  ulcers,  tubercular  ulcers,  tumours  of  the  large  intestine  (be- 
nign or  malignant),  and  acute  or  chronic  intussusception  or  other 
forms  of  intestinal  obstruction. 

The  admixture  of  pus  with  the  stools,  or  the  discharge  of  pus 
from  the  rectum,  is  always  a  striking  symptom.  The  pus  may  come 
from  the  rectum  itself  (ulcerating  tumours  or  ulcers,  rectal  fistulse), 
or  it  may  come  from  intestinal  segments  above  the  rectum.  We 
can  only  determine  the  seat  and  cause  of  the  pus  formation  by 
means  of  repeated  careful  examinations  of  the  entire  intestinal 
canal  and  of  the  fseces  {^ide  Chapter  Y). 

The  fragments  of  new  growths  which  may  be  noticed  by  the 
patients  are  broken-off  pieces  of  cancerous  tumours  (veiy  rare),  or 


THE  HISTOßY  65 

exfoliated  intestinal  polypi.  For  obvious  reasons,  it  requires  a  per- 
sonal examination  to  pass  an  opinion  uj^on  these.  In  intussuscep- 
tion, the  intussusceptum  may  become  gangrenous  and  be  passed. 

Parasites,  especially  segments  of  the  tapeworm,  may  be  recog- 
nised by  the  layman,  but  may  at  times  be  also  confounded  with  a 
number  of  other  things. 

The  importance  of  the  presence  of  food  remnants  will  be  dwelt 
upon  in  the  chapter  on  Faeces. 

The  odour  of  the  normal  stools  is  feculent,  but  not  putrid. 
Should  it  be  offensive,  however,  and  should  the  statements  of  the 
patients  upon  this  point  be  very  positive,  a  personal  examination  of 
the  stools  and  of  the  intestinal  canal  may  be  necessary.  Putrid  ad- 
mixtures with  the  fseces  are  always  a  serious  symptom,  and  are 
generally  due  to  the  breaking  down  of  malignant  tumours  or  of 
ulcers,  to  abscesses,  perforations  from  neighbouring  organs,  etc. 

6.  Tenesmus 

As  a  rule,  tenesmus  indicates  an  affection  of  the  large  intestine. 
Apart  from  dysentery,  which  is  almost  always  accompanied  by  te- 
nesmus, and  from  acute  intestinal  catarrh  with  copious  diarrhoea,  the 
greatest  variety  of  intestinal  disorders  come  into  question  when 
tenesmus  is  complained  of.  For  this  symptom  may  be  occasioned 
by  excessive  coprostasis,  more  frequently,  however,  by  proctitis  and 
periproctitis,  rectal  ulcers  or  catarrh,  haemorrhoids,  prostatitis  and 
prostatic  hypertrophy,  injBLammations  and  malpositions  of  the  uterus, 
ovarian  tumours,  etc.,  and,  finally,  by  foreign  bodies  which  have 
entered  the  rectum  from  above  or  below.  Especially  in  children  is 
tenesmus  a  frequent  symptom  of  acute  and  chronic  intussusception. 
The  condition  in  each  individual  case  must  be  determined  through 
inspection  and  palpation  of  the  rectum  and  of  the  rest  of  the  intes- 
tinal canal. 

7.  Gasteic  Disturbances 

It  can  be  readily  understood  that  gastric  affections  are  frequently 
associated  with  intestinal  disturbances.  The  converse  is  also  true. 
As  regards  acute  intestinal  affections,  especially  those  accompanied 
by  fever  (acute  infectious  enteritis,  perityphlitis,  etc.),  these  require 
no  further  explanation.  Fsecal  vomiting  from  ileus  need  only  be 
mentioned  in  this  place,  as  it  will  be  treated  of  more  in  detail  in  the 
chapter  on  Ileus  in  the  special  part  of  this  work. 

In  chronic  intestinal  diseases,  even  in  those  of  a  malignant  nature, 


66  DISEASES  OF  THE  INTESTINES 

the  appetite,  as  well  as  the  other  functions  of  the  stomach,  maj  be 
entirely  normal.  In  intestinal  tuberculosis,  however,  the  stomach  is 
often  affected.  Here  the  fever  which  is  generally  present  is  an 
important  factor  in  decreasing  the  appetite.  Frequently,  and  with- 
out special  cause,  a  well-marked  chronic  gastritis  may  complicate 
enteritis  (Einhorn,  Biedert,  Oppler).  On  the  other  hand,  however, 
hyperacidity  may  occur  under  the  same  circumstances.  Chronic 
constipation  may  be  associated  with  glandular  gastritis.  The  peri- 
odic vomiting  which  accompanies  intestinal  stenoses,  especially 
those  of  a  severe  type,  is  very  remarkable.  With  l!^othnagel,  we 
may  look  upon  this  as  a  "  regurgitive  contraction."  (For  further 
details,  see  chapter  on  Intestinal  Stenoses,  special  part.)  ISTausea 
and  vomiting  may  also  occur  reflexly,  or  during  long-continued 
intestinal  colics. 

Continued  bilious  vomiting  is  a  very  important  symptom  of 
deeply  seated  duodenal  stenosis,  and  will  be  spoken  of  at  length  in 
the  special  part  of  this  work. 

8.    Subjective  Abdominal  Sensations 

Patients  sometimes  declare  their  main  symptom  to  be  a  feeling 
of  pressure  and  weight  in  the  abdomen.  Occasionally  they  are  able 
to  fairly  accurately  locate  the  seat  of  this  abnormal  sensation.  Such 
subjective  symptoms  are  naturally  only  of  value  when  combined 
with  the  results  of  the  objective  examination. 

9.  Peristaltic  Movements 

Many  patients  will  state  either  of  their  own  accord  or  in  reply 
to  direct  questions  that  they  occasionally  or  constantly  experience 
"a  crawling,  wormlike  sensation,"  sometimes  accompanied  by 
severe  pain  ("peristaltic  unrest").  The  diagnostic  importance  of 
this  symptom  will  be  discussed  in  the  section  on  Inspection. 

LITERATURE 

1.  Treves.     Intestinal  Obstruction.     German  translation  of  Dr.  Arthur  Pollak. 
Leipzig,  1888,  p.  354. 


CHAPTER  lY 

THE  EXAMINATION  OF  THE  PATIENT 

1 .  Inspection 

In  diseases  of  tlie  intestines  the  entire  body,  inclusive  of  the  ex- 
ternal anal  parts  and  the  rectum  should  be  inspected.  Since  inspec- 
tion of  the  anal  region  and  the  rectum  is  usually  associated  with 
palpation  of  the  rectum,  it  will  be  considered  under  that  heading. 

After  we  have  inquired  into  the  general  physical  condition  and 
nutrition  of  the  patient,  we  should  inspect  his  mouth,  to  ascertain  the 
condition  of  his  teeth,  his  tongue,*  and  his  pharynx.  The  patient 
is  thereupon  told  to  disrobe,  and  is  at  first  examined  in  a  standing 
position.  Any  striking  variations  from  the  normal  §hould  at  once 
be  noted  (colour  of  skin,  scars,  growths,  spinal  curvatures  and  pro- 
tuberances, or  depressions  of  any  part  of  the  chest,  etc.). 

Direct  inspection  of  the  abdomen  should  now  begin.  The 
patient  should  either  lie  in  bed  or  upon  a  good  elastic  couch,  with 
his  head  extended  and  the  legs  and  abdominal  muscles  as  fully 
relaxed  as  possible.  The  illumination  must  be  good;  dajdight  is 
best,  but  in  its  stead  we  can  employ  gas  or  electric  light,  either 
direct  or  properly  reflected.  Like  palpation  (q.  v.),  inspection  is 
carried  on  in  two  ways :  during  shallow  and  during  deep  respi- 
rations. 

As  regards  the  shin  over  the  abdomen,  we  have  here  to  look  for 
striae  and  venous  engorgements.  Besides  ascites,  venous  engorge- 
ment of  the  skin  results  from  new  growths  of  the  abdomen  when 
these  compress  the  portal  system.  This  condition  is  not  without 
importance  in  the  diagnosis  of  abdominal  tumours  which  are  deeply 
seated  and  palpable  only  with  extreme  difliculty.  Inspection  also 
enables  us  to  readily  detect  protrusions  or  depressions  of  the  abdo- 
men.    Protrusions  may  be  localized,  or  they  may  extend  over  the 

*  The  condition  of  the  tongue  in  intestinal  diseases  is  of  less  importance  than 
in  gastric  diseases.  On  the  other  hand,  bad  condition  of  the  teeth  may  be  a  defi- 
nite etiological  factor  in  gastric  or  intestinal  catarrhs. 

67 


68  DISEASES   OP   THE  INTESTINES 

entire  abdomen ;  they  may  result  from  abnormal  accumulation 
of  gas  or  fluid.  We  sliould  note  small  differences  in  the  level  of 
the  abdominal  surface,  especially  if  some  segments  of  intestines 
are  more  prominent  than  others.  Herniae  of  the  abdomen  (umbili- 
cal, linea  alba,  ventral,  femoral,  and  inguinal)  are  readily  recog- 
nised, especially  when  the  patient  coughs,  usually  simple  palpa- 
tion is  all  that  is  required  to  make  the  diagnosis.  The  prominence 
above  the  general  surface  of  the  abdomen  of  any  nevi^  growth  is  very 
important.  On  deep  inspiration  we  may  convince  ourselves  of  any 
mobility  of  these  neoplasms,  which  is  a  consideration  of  great  value 
not  only  for  the  diagnosis  but  also  for  the  treatment  of  the  case 
(operation).  It  appears  important  to  me,  therefore,  to  point  out 
that  even  small  new  growths  are  much  more  readily  detected  hy  care- 
ful inspection  with  a  good  light  {a  very  important  point)  than  they 
are  through  palpation. 

Under  especially  favourable  circumstances  (e.  g.,  descensus),  and 
particularly  where  there  is  a  marked  coprostasis,  it  is  possible  to 
recognise  isolated  segments  of  the  large  and  «mall  intestine.  We 
find  both  abnormal  abdominal  depressions  and  prominences.  Basilar 
meningitis  and  lead  colic  present  well-known  classical  examples  of 
depressed  abdomen.  Abnormal  depressions  also  occur  in  marked 
cachexias,  inanition,  esophageal  and  cardial  cancers,  as  well  as  in 
other  non-stenosing  growths  in  the  upper  portion  of  the  digestive 
track.  Much  interest  attaches  itself  to  visible  peristaltic  move- 
ments. These  normally  occur  in  very  emaciated  persons,  particu- 
larly in  women  who  have  frequently  borne  children  {vide  special 
part  of  this  work),  and  are  then,  as  E^othnageP  correctly  points 
out,  limited  to  the  small  intestines.  Yisible  peristalsis  of  the  large 
intestine  is  therefore  a  pathological  condition.  It  may  be  an  intes- 
tinal neurosis  {tormina  ventriculi  nervosa))^  as  illustrated  in  a  strik- 
ing case  which  I  have  recently  demonstrated^,  or  may  constitute  an 
important  and,  if  well  developed,  a  decisive  symptom  of  a  chronic 
intestinal  stenosis.  Since  the  peristaltic  waves  are  most  marked 
above  the  point  of  stenosis,  we  can  in  a  general  way  determine  the 
seat  of  the  obstruction.  Besides  these  forms,  which  really  represent 
but  an  exaggerated  and  for  the  most  part  a  painless  type  of  normal 
peristaltic  movement,  there  is  a  second  form,  the  tetanic  intestinal 
contraction ;  this  varies  according  to  the  emptiness  or  fulness  of 
the  intestines.  As  instances  of  tetanic  contraction  with  empty 
intestines,  Nothnagel  mentions  cerebral  meningitis  and  lead  colic. 
He  thinks  that  in  rare  cases  the  contracted  coils  are  visible.     This, 


THE   EXAMINATION  OP   THE   PATIENT  69 

however,  has  never  been  my  experience  ;  on  the  other  hand,  tetanic 
contractions  with  filled  intestines  are  more  frequent,  and  constitute 
an  exceedingly  important  diagnostic  symptom.  One  may  see  a 
rounded  elevation  suddenly  appear  in  a  circumscribed  portion  of  the 
intestine  and  accompanied  by  most  severe  pain,  gradually  become 
more  and  more  prominent,  become  rigid,  and  then  suddenly  sink 
back  again.  This  is  often  accompanied  by  loud  gurgling  and  rum- 
bling sounds  and  a  subsidence  of  the  pain,  l^othnagel  ^  has  very 
aptly  applied  the  name  "  intestinal  rigidity  "  to  this  condition.  The 
gradual  increase  in  intensity,  the  pause  at  the  acme,  and  the  sudden 
subsidence  may  all  be  better  appreciated  by  placing  the  hand  over 
the  part  than  by  inspection.  This  form  of  tetanic  contraction 
always  points  to  an  obstruction  of  the  intestinal  passage ;  however, 
it  gives  us  no  information  regarding  the  nature  of  the  obstruction 
— i.  e.,  whether  within  or  without  the  intestinal  canal,  whether  caused 
by  a  foreign  body  or  by  disease  of  the  mucous  membrane,  etc.  The 
causes  of  "intestinal  rigidity"  will  be  referred  to  in  the  special 
part  of  the  present  work. 

2.    Palpation 

A.  Palpation  of  the  Abdomen 

The  great  importance  as  well  as  the  difficulties  of  palpation 
have^  been  dwelt  upon  elsewhere^.  What  has  there  been  stated 
applies  to  a  greater  degree,  if  possible,  to  the  intestines.  In  the 
following  the  most  important  points  in  regard  to  the  technic  of 
palpation  are  again  given. 

1.  A  good  couch,  not  too  soft,  and  accessible  from  all  sides, 
should  be  used  for  the  examination  (a  lounge  is  preferable  to  a  bed). 

2.  The  patient  should  lie  in  the  horizontal  position,  with  the 
head  extended  and  as  low  as  possible. 

3.  The  legs  as  well  as  the  rest  of  the  body  should  be  as  fully 
relaxed  as  possible  (anaesthetic  posture).  I  have  very  seldom  seen 
any  advantage  from  the  drawing  up  of  the  lower  extremities  which 
is  still  often  recommended. 

4.  Palpation  should  be  conducted  in  a  warm  room,  and  only 
with  warm  hands,  for  otherwise  the  abdominal  walls  will  contract 
at  the  slightest  touch,  and  deep  exploration  become  impossible. 

5.  The  attention  of  the  patient  is  to  be  distracted  from  the  ex- 
amination by  questioning  him  regarding  his  age,  heredity,  etc.,  and 
by  having  him  stretch  out  his  tongue,  raise  his  arms,  etc. 

6 


YO  DISEASES   OP   THE  INTESTINES 

6.  Palpation  at  first  should  include  the  superficial  portions  of 
the  abdomen,  and  only  very  gradually  should  the  deeper  parts  be 
explored. 

T.  The  condition  of  fulness  of  the  abdominal  cavity  at  the  time 
of  examination  is  very  important.  The  distention  of  the  abdominal 
cavity  with  gas  or  fluid,  of  the  stomach  with  food,  of  the  large  in- 
testine with  faecal  masses,  and  of  the  bladder  with  urine,  may  at 
times  interfere  with  the  examination,  but,  as  will  be  later  shown, 
this  is  not  always  the  case.  We  should  therefore  make  it  a  rule 
never  to  make  a  diagnosis  at  the  first  visit,  but  should  point  out  the 
necessity  of  a  further  examination  after  removal  of  the  above-men- 
tioned conditions. 

8.  Always  palpate  in  the  right  and  left  lateral  positions,  as  well 
as  in  the  dorsal,  for  frequently  growths  of  the  stomach,  of  the  intes- 
tines, or  of  other  organs,  can  not  otherwise  be  palpated.  Bimanual 
palpation  is  especially  to  be  recommended  for  the  examination  in 
the  lateral  position. 

9.  For  the  better  recognition  of  tumours,  enlargements,  or  alter- 
ations in  position  of  abdominal  organs,  differentiated  otherwise  with 
great  difficulty,  Y.  Chalapowski,  Lennhof,  G.  See,  Schuster,  Berk- 
han,  and  others,  have  recently  strongly  recommended  palpation  in  a 
warm  full  bath.  Although  I  have  had  no  personal  experience  with 
this  method,  in  spite  of  its  inconvenience,  it  appears  to  me  to 
possess  a  number  of  advantages  which  would  justify  a  more  exten- 
sive trial. 

In  palpating  the  abdomen  we  may  proceed  in  one  of  two  ways : 
Either  fix  upon  and  at  once  explore  some  point  that  attracts  atten- 
tion, or  examine  systematically.  The  former  method  is  to  be  rec- 
ommended only  to  the  experienced,  while  the  latter  is  to  be  recom- 
mended to  the  beginner.  I  would  advise  the  following  method  of 
procedure  :  Examination  of  the  abdominal  wall  for  oedema,  emphy- 
sema of  the  skin,  excessive  fat,  lipomata,  etc. ;  examination  of  the 
epigastrium,  paying  special  attention  to  splashing  and  succussion 
sounds,  etc. ;  examination  of  the  right  and  left  lobes  of  the  liver, 
the  region  of  the  small  intestines  from  the  pylorus  downward  to 
the  umbilical  region.  The  hernial  canals  should  be  palpated ;  also 
the  region  of  the  caecum  (McBurney 's  point  midway  between  the 
anterior  superior  spine  and  the  umbilicus).  From  the  caecum  the 
examination  is  to  be  continued  along  the  ascending,  transverse, 
and  descending  colon,  and  the  sigmoid  flexure.  The  ascending 
and  descending  colon  are  best  palpated  in  the  right  and  left  lateral 


THE  EXAMINATION   OF   THE   PATIEKT  Yl 

postures  respectively.  At  the  same  time  tlie  condition  of  the  kid- 
neys (dislocation,  fluctuation,  and  tumours)  and  of  the  spleen  may- 
be determined. 

This  plan  is  of  course,  to  a  certain  extent,  schematic,  and  assumes  that  the 
intestines  are  in  their  normal  position.  We  must,  however,  reckon  upon  jaossible 
anomalies  of  single  segments,  especially  those  of  the  very  mobile  j^ortions  of  the 
large  intestines.  (Compare  further  remarks  upon  this  on  page  21  et  seq.,  and  also 
the  chapter  on  Displacements  of  the  Intestines,  in  the  special  part  of  this  work.) 

Under  favourable  conditions  it  is  undoubtedly  possible  to  pal- 
pate certain  segments  of  the  intestines.  Obrastzow  "*,  who  has  thor- 
oughly studied  the  technic  of  this  subject,  has  obtained  remark- 
able results  by  palpation.  He  was  able  to  locate  the  caecum  in 
51.47  per  cent  of  the  men  and  in  58  per  cent  of  the  women  he 
had  examined ;  the  transverse  colon  in  23  per  cent  and  the  sigmoid 
flexure  in  65  per  cent  of  all  his  cases,  unfortunately  these  results 
are  not  accompanied  by  post-mortem  records,  and  therefore  they 
lose  much  of  their  statistical  value.  As  pointed  out  in  the  oft- 
quoted  instructive  treatise  of  Curschmann,  the  greatest  caution  must 
be  exercised  in  accepting  palpatory  results  of  the  large  intestines, 
since  the  latter  are  so  frequently  displaced.  ]S[evertheless,  we  may 
safely  assert  that  the  sigmoid  flexure  is  the  most  easily  palpated 
segment,  the  transverse  colon  the  most  difficult,  while  the  caecum 
occupies  a  position  between  the  two.  It  is  frequently  possible  to 
palpate  the  sigmoid  flexure  and  the  ascending  colon  from  their  be- 
ing filled  with  scybalae ;  upon  palpating  the  lower  portion  of  the 
ileum  or  csecum,  the  impression  is  conveyed  as  if  of  a  thin  pasty 
mass  under  the  fingers,  and  one  can  hear  and  feel  the  gurgling 
sounds,  formerly  considered  an  important  symptom  of  typhoid 
fever.  These  signs,  however,  are  to  be  accepted  in  a  diagnostic 
sense  only  after  most  careful  consideration.  Abnormal  thinness  of 
the  abdominal  walls  and  distention  of  the  bowel  by  fseces  render 
palpation  of  the  large  intestine  much  easier.  In  the  presence  of 
such  conditions,  it  is,  I  believe,  possible  to  map  out  the  entire  large 
intestine.  To  determine  intestinal  displacements  it  might  even  be 
advisable  to  bring  about  an  artificial  coprostasis. 

Kecently,  Edebohls^  has  claimed  that  the  vermiform  appen- 
dix, especially  in  women,  is  often  palpable,  and  that  from  the  con- 
dition found  one  can  tell  whether  in  a  given  case  the  appendix  is  a 
normal  or  an  abnormal  one.  He  recommends  that  one  should 
press  as  deeply  as  possible  toward  the  posterior  wall  of  the  abdo- 
men and  floor  of  the  pelvis,  keeping  to  the  outer  side  of  the  iliac 


72  DISEASES   OP   THE   INTESTINES 

artery.  I  have  never  succeeded  in  satisfactorily  palpating  the 
appendix.  In  my  experience,  it  is  easier  to  palpate  isolated  coils  of 
the  small  intestines,  particularly  in  enteroptosis. 

This,  however,  is  of  no  practical  advantage,  for  it  will  rarely  be 
possible  to  recognise  what  particular  segment  is  felt.  I  would  here 
remark  that  Obrastzow  ^  points  out  the  importance  of  palpation  of 
the  ileum  for  the  diagnosis  of  typhoid,  claiming  that  the  gut  appears 
thickened,  uneven,  and  painful. 

As  in  the  stomach,  so  also  in  special  palpation  of  isolated  intes- 
tinal segments  the  following  points  come  up  for  consideration. 

(a)  Sensitiveness  to  Pressure  ;   Pain  {CirGumscrihed  or  Diffuse) 

We  shall  first  give  a  few  practical  preliminary  remarks.  All 
portions  of  the  intestines  are  painful  upon  rough  handling,  the 
caecal  region  more  so  than  the  rest ;  furthermore,  owing  to  the 
adjacent  sympathetic  fibres,  pressure  over  the  large  blood-vessels 
causes  pain,  especially  in  women  whose  abdominal  walls  are  relaxed 
from  frequent  childbirths,  and  in  very  emaciated  men.  In  the 
palpation  of  isolated  intestinal  areas  of  anxious  and  excited  indi- 
viduals I  have  frequently  met  with  a  "  pseudo-painfulness."  It  is 
well  to  have  the  painful  areas  pointed  out  and  to  re-examine  them 
after  a  few  moments.  We  can  thereby  convince  the  patients  them- 
selves of  their  error.  In  this  connection  I  wish  also  to  call  atten- 
tion to  a  general  hyperalgesia  of  the  abdominal  wall  not  infre- 
quently met  with  in  neurasthenics. 

Practically,  we  should  distinguish  between  pressure  sensitiveness 
and  pain.  Thus,  an  acutely  inflamed  appendix,  or,  in  acute  dysentery, 
the  sigmoid  flexure  and  the  descending  colon  are  painful,  whereas 
in  chronic  enteritis  the  large  intestine  is  but  slightly  sensitive  to 
pressure.  The  differentiation  of  such  degrees  of  sensitiveness  must 
be  carefully  practised  and  studied.  Yery  important,  too,  is  the 
differentiation  between  a  localized  and  a  diffuse  pressure  sensitive- 
ness. In  ulcer  of  the  duodenum  we  meet  with  a  very  circumscribed 
area  of  pain,  beyond  whose  limits  pressure  made  with  the  necessary 
precaution  is  absolutely  painless  ;  on  the  other  hand,  in  appendicitis 
with  diffused  peri-appendicular  abscess  the  entire  region  of  the 
csecum,  or  even  the  entire  ascending  colon,  may  be  painful  on 
pressure.  Again,  in  general  peritonitis  the  entire  abdomen  is  pain- 
ful even  to  the  slightest  touch.  Multiple  circumscribed  sensitive- 
mess  is  found  in  catarrh  of  the  small  intestines  complicated  by  fol- 
llcvular  ulcers  (for  the  most  part  tubercular) ;  it  may,  however,  be 


THE   EXAMINATION   OF  THE   PATIENT  73 

absent.  When  present,  it  can,  when  viewed  with  a  certain  amount 
of  reserve  and  in  connection  with  other  symptoms,  acquire  a  diag- 
nostic value.  I  have  often  observed  a  diffuse  pressure  sensitiveness 
in  chronic  sigmoiditis.  This  I  regard  as  an  important  symptom  to 
which  little  attention  has  been  paid.  I  will  refer  to  it  more  in  detail 
in  the  chapter  on  Enteritis  (special  part).  A  pressure  sensitiveness, 
at  first  localized,  but  later  diffused,  may  coexist  with  malignant 
growths,  stenosis  from  other  causes,  intussusception,  and  volvulus. 
Further  details  of  this  subject  must  also  be  reserved  for  the  special 
part  of  this  work. 

(b)  Splashing  Sounds  {Clapotage)  •  Succussion  Sounds 

In  my  experience,  intestinal  splashing  sounds  occur  only  in  the 
large  intestine,  and  only  under  certain  conditions.  As  far  as  I  can 
learn  from  the  literature,  this  subject  has  received  but  little  atten- 
tion ;  it  therefore  seems  proper  to  consider  it  more  in  detail.  A 
certain  relaxation  of  the  intestinal  walls  as  well  as  the  presence  of 
fluid  or  thin  pasty  contents  are  necessary  for  the  production  of 
splashing  sounds.  Furthermore,  the  abdominal  walls  must  be  suffi- 
ciently yielding,  so  that  the  wave  of  contact  may  be  readily  trans- 
mitted to  the  intestines.  Thinness  of  the  abdominal  wall  and  lax- 
ity of  tbe  intestines  are  normally  present  in  women  who  have  born& 
many  children.  It  is  different,  however,  with  regard  to  the  physi- 
cal state  of  the  intestinal  contents.  From  the  investigations  of 
Macfadyen,  I^encki,  and  Siebers  (p.  45)  we  know  that  normally  the 
contents  of  the  lower  part  of  the  ileum  are  of  a  thin  pasty  consist- 
ency ;  as  such  they  enter  the  caecum,  and  there  gradually  assume 
a  firm  cylindrical  shape.  Normally^  therefore,  a  splashing  sound  is 
never  elicited  beyond  the  caecum,  or  the  ascending  colon. 

To  make  certain  whether  or  not  substances  of  pasty  consistency  can  cause 
splashing  sounds  in  the  large  intestines,  I  directed  my  former  assistant,  Dr. 
Ehrlich,  to  ascertain  whether  splashing  sounds  could  be  elicited  in  the  large 
intestine  after  injections  of  large  quantities  of  thick  pasty  soups.  It  was  found 
that  these  sounds  could  be  distinctly  elicited  in  the  sigmoid  flexure,  and  in  two 
cases  in  the  caecum,  and  more  particularly  in  the  transverse  colon.  Marked 
liquefaction  of  the  contents  of  the  large  intestines  is  still  more  favourable  for 
the  production  of  splashing  sounds ;  under  such  circumstances  they  may  be 
heard  even  over  extensive  areas. 

It  appears  possible,  therefore,  without  special  preparation,  to 
determine  approximately,  the  position  of  one  or  more  segments  of 
the  intestines  by  means  of  the  splashing  sounds,     l^aturally,  this 


Y4  DISEASES   OF   THE  INTESTINES  • 

can  only  be  accomplished  with  normal  situation  and  an  absence  of 
gastric  succussion  sounds. 

I  was  the  first  to  recommend  methodical  filling  of  the  large 
intestine  with  measured  amounts  of  water  for  determination  of  the 
splashing  sounds'''.  This  method  is  somewhat  cumbersome,  and  as. 
yet  not  well  known  ;  it  does,  however,  give  us  some  diagnostic  data. 
If  after  thoroughly  emptying  the  intestines  of  a  healthy  individual, 
we  allow  lukewarm  water  to  flow  slowly  into  the  rectum  through 
a  soft-rubber  tube  and  funnel,  all  segments  of  the  large  intestine 
will  gradually  fill  up.  After  500  to  600  cubic  centimetres  have  been 
introduced,  a  splashing  sound,  more  or  less  distinct,  may  be  obtained, 
at  first  in  the  region  of  the  sigmoid  fiexure,  but  later  also  in  the 
transverse  colon,  and  finally  in  the  caecal  region.  Under  favourable 
conditions  a  slight  succussion  sound  can  be  heard  upon  changing 
the  position  of  the  body.  In  marked  atony  of  the  large  intestine 
we  will  obtain  a  splashing  sound  in  the  above-mentioned  places  after 
only  200  to  300  cubic  centimetres  have  been  introduced.  Should, 
however,  the  splashing  sound  be  heard  at  a  point  other  than  where 
it  normally  ought  to  be  (e.  g.,  far  below  the  umbilicus),  it  would 
indicate  displacement  of  the  segments  of  the  large  intestine  in  ques- 
tion. As  in  the  stomach,  downward  displacement  or  a  dislocation 
of  the  segments  of  the  intestine  frequently  coexists  with  atony. 
J.  Friedenwald^  has  also  employed  this  method  and  confirms  its 
diagnostic  value. 

Just  as  we  can  obtain  splashing  sounds  in  the  intestines  filled 
with  water  by  striking  them  with  the  tips  of  the  fingers,  so  we  may 
also  readily  elicit  succussion  sounds  wherever  there  is  an  excessive 
relaxation  or  a  dilatation  of  the  intestinal  walls  by  shaking  the 
patients  or  by  having  them  rapidly  change  their  position.  Suc- 
cussion sounds  are  very  readily  heard  in  the  sigmoid  flexure  or  the 
descending  colon. 

(c)  New  Growths ;   Fcecal  Tumours;  Adhesions 

]^ew  growths  occur  in  all  parts  of  the  intestinal  canal,  but 
increase  in  frequency  as  we  go  downward.  Malignant  tumours 
(cancer,  sarcoma,  lymphosarcoma,  tubercular  tumours)  are  met  with 
more  often  than  benign  tumours  (myomata,  fibromata,  polyps,  ade- 
nomata, angioraata,  syphilomata,  etc.).  If  in  the  following  discus- 
sion we  speak  of  tumours  in  general,  we  nevertheless  have  the 
malignant  new  growths  principally  in  view. 

When  a  new  growth  is  found  in  the  abdominal  cavity  and  ques- 


THE   EXAMINATION  OP   THE   PATIENT  75 

tion  of  its  connection  with  the  intestines  is  raised,  we  should  first 
of  all  consider  all  those  other  organs  to  which  the  tumour  might 
possibly  belong.  Palpation  alone  is  generally  not  sufficient ;  other 
methods  of  examination — the  examination  of  the  stomach  contents, 
inflation  of  the  stomach  and  intestines,  injection  of  water,  as  well  as 
other  clinical  phenomena  (urine,  blood,  and  especially  examination 
of  the  genitals) — must  be  brought  to  our  aid.  As  in  other  abdominal 
tumours,  in  intestinal  tumours  the  jpositioii,  mobility,  size,  consistency, 
sensibility,  and  respiratory  mobility,  have  to  be  determined. 

As  regards  the  position  of  a  new  growth,  that  is  determined  in 
the  first  place  by  the  normal  position  of  the  intestinal  segment  with 
which  it  is  connected.  The  position  will  depend  very  much  upon 
the  mobility  of  the  intestinal  segment  in  question.  For  instance,  a  • 
cancer  of  the  pylorus  may  be  found  in  the  region  of  the  caecum,  or 
a  perityphlitis  below  the  right  lobe  of  the  liver. 

To  begin  with  the  small  intestines,  the  duodenum  is  compara- 
tively firmly  fixed,  so  that  its  tumours  can  very  seldom  cause  marked 
alterations  in  its  position. 

Owing  to  their  large  and  more  freely  movable  mesentery,  tumours 
of  the  jejunum  and  of  the  ileum  have  a  somewhat  greater  mobility. 
As  JN^othnagel  ^  very  correctly  observes,  this  may  lead  to  great  diffi- 
culty in  the  differentiation  between  tumours  of  the  large  and  small 
intestines.  The  csecum  and  the  ascending  and  descending  colon  are 
the  least  movable  segments  of  the  large  intestine,  while  the  trans- 
verse colon  and  the  sigmoid  flexure  have  the  widest  range  of  motion. 
In  tumours  of  these  segments  there  will  very  probably  be  a  disloca- 
tion of  the  parts.  The  tumour  itself  may  tug  upon  the  portion  of 
the  intestine,  dragging  it  laterally  or  downward ;  or  else  the  bowel 
may  become  distended  above  the  site  of  the  stenosis,  and  becom- 
ing abnormally  loaded,  may  drag  the  intestinal  segment  at  first  par- 
tially, later  completely  downward ;  finally,  in  consequence  of  begin- 
ning emaciation,  there  may  be  a  relaxation  of  the  fixation  bands 
with  a  resulting  alteration  in  position  of  the  intestinal  segments. 

Furthermore,  we  must  distinguish  between  passive  and  active 
(manual)  mobility.  I  have  found  passive  mobility  of  intestinal 
tumours  to  be  rare ;  active  motion  occurs  either  not  at  all,  or  else  to 
a  very  striking  extent.  The  mobility  of  the  tumour  will  depend 
principally  upon  whether  a  ptosis  of  the  bowels  has  taken  place,  and, 
further,  upon  the  presence  or  absence  of  adhesions.  The  nature  of 
the  tumour  itself  is  also  very  important.  Regarding  the  sise  of 
the  tumour,  this,  as  hi  the  stomach,  will  vary  considerably,  accord- 


Y6  DISEASES   OF   THE   INTESTINES 

ing  to  the  stage  of  the  process.  I  have  seldom  observed  intestinal 
growths  acquire  such  dimensions  as  those  of  the  stomach ;  usually 
they  are  very  much  smaller.  Sarcomata  and  benign  growths  form 
an  exception ;  they  may  reach  enormous  dimensions. 

The  consistency  of  the  growth  depends  upon  its  origin  and 
malignancy.  Cancers  are  hard  and  nodular;  sarcomata  hard  and 
smooth,  and  they  not  infrequently  have  a  central  soft  or  even  fluctu- 
ating area.  Benign  growths,  as  well  as  intussuscepted  portions  of 
the  intestines,  are  smooth  and  uniform,  while  abscesses  and  cysts 
always  impart  the  feeling  of  fluctuation  to  the  examining  finger. 

The  sensitiveness  of  intestinal  growths  is  likewise  subject  to  the 
greatest  variations.  They  are,  perhaps,  never  entirely  painless ;  the 
pressure  sensitiveness  of  benign  growths  is  very  much  less  than  that 
of  malignant  ones.  Upon  the  whole,  however,  no  great  weight 
need  be  attached  to  the  degree  of  sensibility  of  the  intestineo. 

All  parts  of  the  intestines  are  more  or  less  movable  with  respira- 
tion, most  so  where  the  intestinal  wall  is  thin,  and  poor  in  fat ;  on 
the  other  hand,  adhesions  of  organs  directly  connected  with  the 
diaphragm  (liver,  stomach,  and  spleen)  may  have  a  disturbing  influ- 
ence. Yery  little  diagnostic  significance  attaches  itself  to  the 
respiratory  mobility  of  intestinal  growths.  The  question  of  exist- 
ing adhesions  is  best  determined  under  narcosis. 

FoBcal  tumours  play  such  an  important  part  among  intestinal 
growths,  and  so  frequently  give  rise  to  errors  and  confusion  in 
intestinal  diseases,  that  they  require  special  consideration.  They 
may  give  rise  to  errors  in  two  ways :  first,  in  simulating  new 
growths,  and,  secondly,  in  causing  existing  new  growths  to  appear 
larger  than  they  really  are.  In  such  cases,  usually,  the  diagnosis 
can  not  at  once  be  made;  we  should  allow  ourselves  more  time  and 
observe  the  effect  of  internal  and  external  laxative  measures.  As  a 
rule,  the  consistency  of  the  growth  in  question  will  give  us  a  useful 
diagnostic  hint.  Apart  from  the  so-called  enteroliths,  fsecal  tumours 
are  generally  of  a  somewhat  doughy  consistency,  and  retain  the 
impression  of  the  finger,  especially  after  rectal  enemata  of  oil  or  of 
soap  (which  tend  to  soften  them).  Even  after  such  enemata  the 
peripheral  portion  of  the  fseces  may  remain  hard  {Randkotk) 
and  simulate  a  tumour,  notwithstanding  that  frequent  voluminous 
evacuations  {Centralhoth)  have  taken  place.  This  experience,  which 
has  been  that  of  absolutely  reliable  clinicians,  calls  for  the  greatest 
caution  in  the  determination  of  the  nature  of  doubtful  tumours. 
The  situation  can  usually  be  determined,  especially  upon  repeated 


THE   EXAMINATION  OP   THE   PATIENT  77 

examinations,  altliougli  a  very  instructive  case  described  by  Noth- 
nagel shows  that  even  then  errors  can  not  always  be  excluded. 
The  history,  the  status,  the  clinical  course,  in  short,  everything  in 
Nothnagel's  case,  indicated  cancer  of  the  caecum,  while  the  autopsy 
showed  an  ulcerative  tubercular  stricture  in  the  beginning  of  the 
ascending  colon. 

Gersuny  ^°  believes  that  the  difficulties  in  diagnosis  so  often  caused 
by  faecal  tumours  have  been  overcome  by  the  discovery  of  a  peculiar 
symptom  which  he  describes  as  "  the  adhesive  sign "  (Klebesymp- 
tom) ;  viz.,  if  the  finger  be  very  firmly  pressed  upon  the  faecal  mass, 
the  intestinal  mucous  membrane  will  become  adherent  to  the  vis- 
cous faeces,  becoming  free  again  when  the  pressure  is  discontinued. 
Gersuny  states  that  we  can  feel  the  mucous  membrane  loosening 
itself,  and  that  such  a  sensation  is  characteristic  of  a  faecal  tumour. 
HofmokP^  could  not,  however,  convince  himself  of  the  existence  of 
this  "  adhesive  sign,"  and,  like  myself,  regards  the  impressibility  of 
the  faecal  tumour  as  the  most  characteristic  symptom. 

Under  favourable  conditions  adhesions  between  the  portions 
of  the  intestines  may  be  palpated  and  recognised  as  cicatricial 
strands ;  more  frequently,  however,  they  are  suspected  rather  than 
recognised. 

B.    Inspection    and    Palpation    of   the    Region    of   the  Anus 
AND   Rectum  ;    Examination   with   Rectal   Bougies 

Palpation  is  the  most  certain  method  of  acquainting  ourselves 
with  diseased  conditions  of  the  rectum ;  in  many  cases,  however,  it 
must  be  supplemented  by  inspection  and  the  use  of  bougies.  Pal- 
pation of  the  rectum  should  be  preceded  by  inspection  of  the  anus. 
The  patient  is  to  be  examined  either  in  the  lateral  or  in  the  knee- 
chest  position.  Personally,  for  complete  examination  of  the  rectum 
and  anus  I  prefer  the  latter  position.  With  good  illumination  we 
can  inspect  external  haemorrhoids,  fissures,  intertrigo,  pruritus  ani, 
furuncles,  phlegmons,  external  fistulae,  etc.  At  the  same  time  we 
can  at  once  learn  whether  or  not  any  pathological  secretions  (blood, 
pus,  or  mucus)  come  from  the  anus.  Inspection  is  best  followed 
immediately  by  palpation.  When  a  patient  complains  of  rectal 
trouble,  rectal  palpation  should  never  be  neglected.  It  not  infre- 
quently happens  in  very  timid  or  prudish  persons,  especially  women, 
that  we  meet  with  opposition,  and  we  should  then,  quietly  but  firmly, 
explain  the  absolute  impossibility  of  forming  an  opinion  without 


78  DISEASES   OP   THE  INTESTINES 

direct  local  examination.  Even  in  apparently  harmless  cases  I  do 
not  hesitate  to  point  out  the  possible  existence  of  serious  disease  of 
the  rectum.  This  very  quickly  has  the  desired  effect.*  Palpation 
of  the  rectum  is  also  absolutely  unavoidable  in  other  chronic  stomach 
and  intestinal  affections,  which  at  first  glance  may  appear  to  have 
nothing  in  common  with  the  I'ectum. 

In  my  Diagnosis  and  Therapeutics  of  the  Diseases  of  the  Stomach 
(Part  I,  p.  72)  I  have  emphatically  stated  that  we  ought  never  to  be 
satisfied  with  the  mere  diagnosis  "  hsemorrhoids,"  but  should  always 
explore  the  rectum  very  carefully.  Sometimes  a  human  life  Tnay 
he  lost  through  such  utterly  inexcusable  negligence. 

Tbchnic  of  Rectal  Palpation 

As  a  rule,  the  examination  is  conducted  in  the  knee-chest  or  lat- 
eral position  (see  above). 

The  finger  should  be  well  anointed  with  borovaselin  (oil  or 
glycerin  are  less  commendable). f  The  examination  itself  must 
never  be  a  forcible  one,  and  should  consist  in  gentle  rotatory  move- 
ments, and  where  the  patient  already  complains  of  rectal  pain 
should  be  carried  out  with  particular  care.  In  some  cases  cocainiza- 
tion  of  the  rectum  may  be  advisable,  though  I  find  it  can  generally 
be  dispensed  with. 

Passing  the  examining  finger  slowly  forward,  we  learn  the  con- 
dition of  the  mucous  membrane,  the  presence  of  foreign  bodies  or 
of  new  growths,  and  the  patency  of  the  rectal  lumen ;  furthermore, 
the  condition  of  the  prostate,  and  in  women,  such  anomalies  of  the 
sexual  organs  as  can  be  recognised  by  palpation  through  the  rectum. 

If  the  disease  process  be  situated  high  up,  and  is  entirely  inac- 
cessible, or  accessible  only  with  great  difficulty  in  either  of  the  two 
mentioned  positions,  we  may  reach  it  with  the  patient  in  the  dorsal 

*  Other  circumstances  may  at  times  lead  to  difficulty  in  the  exploration  of  the 
rectum.  Kelsey,  the  experienced  New  York  rectal  specialist,  relates  the  following 
characteristic  story:  "  A  foreigner  told  me,  when  I  proposed  it  [rectal  examination], 
that  he  had  entirely  too  great  respect  for  me  to  allow  such  a  thing.  My  only 
answer  was  that  1  had  too  great  respect  for  myself  to  treat  him  without  knowing 
what  was  the  matter.     That  helped,  and,  "  Kelsey  concludes,"  we  parted  amicably." 

[f  To  prevent  the  faecal  odour  from  clinging  to  the  finger  after  a  rectal  examina- 
tion, it  is  a  very  effectual  plan  before  the  "  preliminary  anointing"  to  liberally 
scrape  ordinary  soap  under  the  free  edge  of  the  finger  nail  and  between  the  cuticle 
of  the  finger  and  the  matrix  of  the  nail.  The  so-called  "  finger  cots  "  protect  the 
examining  finger  from  infection  and  faseal  smell,  and  when  made  of  the  proper 
thinness  do  not  interfere  with  the  palpatory  sense. — Tb.] 


THE  EXAMINATION   OF  THE   PATIENT  79 

position  and  by  suitable  pressure  in  the  left  iliac  region.  In  like 
manner  w^e  may  succeed  with  the  patient  in  a  standing  position, 
when  the  examiner  should  be  on  one  knee  and  support  the  elbow 
of  the  examining  hand  upon  the  other  knee  bent  at  a  right  angle. 
At  the  same  time  the  patient  should  be  asked  to  make  strong  pres- 
sure downward. 

At  the  time  of  the  first  examination  it  is  very  desirable  to  make 
the  digital  exploration  of  the  rectum  as  carefully  and  fully  as  pos- 
sible, so  that  we  ascertain  all  that  can  be  learned  through  palpation. 

In  some  cases  the  introduction  of  one  finger  is  not  sufiicient  to 
palpate  the  entire  diseased  area.  For  this  class  of  cases  Simon, 
many  years  ago,  recommended  the  introduction  of  the  entire  hand 
into  the  rectum.  This  procedure,  which  is  by  no  means  harmless, 
can  of  course  be  carried  out  only  under  general  ansesthesia.  In 
consequence  of  the  resulting  relaxation  of  the  sphincter,  one  or  two 
fingers  usually  suffice  for  the  exploration,  and  the  entire  hand  is 
necessary  in  isolated  cases  only.  In  rare  cases,  however,  bloodless 
distention,  or  even  slitting  up  of  the  sphincter  (sphincterotomia  pos- 
terior recti),  must  be  undertaken.  Since  both  of  these  are  usually 
preparatory  to  operations  on  the  rectum,  we  must  refer  the  reader 
for  further  details  to  surgical  text-books. 

Examination  under  narcosis  is  also  indicated,  either  where  the 
nature  of  the  disease  can  not  be  otherwise  determined  because  of 
excessive  painfulness  of  the  exploration,  or  else  where  the  disease, 
being  known  (e.  g.,  cancer),  the  determination  of  its  extent,  particu- 
larly upward,  is  attended  by  great  difficulties,  or,  finally,  where  new 
growths  are  barely  accessible  to  the  finger. 

If  inspection  or  examination  with  bougies  is  also  required,  it  is 
best  to  proceed  with  these  immediately  after  palpation.  The  patient 
is  thus  spared  the  excitement  attendant  on  every  rectal  examination, 
and,  what  is  most  important  also,  the  uncertainty  of  diagnosis. 

Ocular  inspection  of  the  rectum  is  best  conducted  on  an  operat- 
ing table,  in  the  lithotomy  position,  whereby  the  sacrum  lies  on  a 
level  with  the  examiner's  chest.  The  knee-chest  position  may  also 
be  used.  The  examination  should  be  made  with  the  aid  of  a  suit- 
able speculum.  The  number  of  these  specula  almost  equals  those 
for  the  vagina.  They  are  all  best  described  in  the  catalogues  of 
instrument  makers.  For  practical  purposes  most  of  them  are  too 
complicated  and  clumsy.  With  the  observance  of  the  precautions 
described  below,  one  usually  succeeds  with  a  simple  Sims's,  Simon's, 
or  a  Czerny's  speculum,  the  latter  having  given  me  excellent  serv- 


80  DISEASES   OP   THE  INTESTINES 

ice  on  account  of  the  shortness  of  the  one  end.  A  bivalve  specu- 
lum is  also  very  good.  With  proper  illumination,  one  obtains  a. 
satisfactory  picture  of  the  internal  rectum. 

Palpation  should  always  precede  the  introduction  of  the  specu- 
lum. The  presence  or  absence  of  fseces  in  the  rectum  can  thus  be 
determined.  If  present,  they  must  be  removed  through  irrigation 
with  lukewarm  water  or  weak  lysol  solutions,  or  else  manually. 

The  introduction  of  a  speculum  is  very  much  facilitated  by  the 
relaxation  of  the  rectum.  This  is  readily  accomplished  by  the  knee- 
chest  position,  in  which  the  abdominal  organs  fall  forward  and  nega- 
tive pressure  in  the  rectum  results ;  the  latter  fills  with  air  and 
its  walls  stand  apart.  I  have  convinced  myself  that  deep  inspira- 
tion combined  with  passing  the  finger  into  the  rectum  very  much. 
facilitates  the  passing  of  the  speculum.  If  the  instrument  be  uni- 
formly and  liberally  anointed  with  a  fatty  substance,  its  introduc- 
tion will  be  attended  by  no  difficulty.  With  a  good  natural  or 
artificial  light  one  can  carefully  inspect  all  pathological  conditions 
of  the  rectum.  This  has  recently  led  Kelly  ^^  to  recommend  the 
introduction  of  cylindrical  specula  with  a  uniform  diameter  of  22 
millimetres  and  a  length  varying  from  14  to  35  centimetres,  and 
furnished  with  obturators.  They  are  introduced  with  the  patient 
in  the  knee-chest  position.  As  soon  as  the  speculum  has  passed  the 
sphincter  the  rectum  fills  with  air,  and  an  entirely  unobstructed  view 
of  the  rectal  cavity  is  thus  obtained. 

Attempts  have  been  made  to  illuminate  the  rectum  just  as  in 
other  cavities  in  the  body.  J.  Leiter,  of  Vienna,  constructed  an 
instrument  for  this  purpose  ^^,  which,  however,  appears  to  have 
been  put  to  little  practical  use.  After  introducing  the  speculum 
into  the  rectum,  one  may  employ  either  reflected  electric  illumina- 
tion, or  more  simply,  direct  electric  illumination. 

Herzstein  has  lately  constructed  an  instrument  which  I  have 
found  very  useful  for  the  examination  of  the  rectum  (Fig.  11).  It 
consists  of  several  metal  tubes  (A),  varying  in  length  from  10  to  34 
centimetres,  and  furnished  with  metal  obturators  (£)  for  the  pur- 
pose of  easier  introduction.  The  screw  (d)  fastens  the  obturator  to 
the  metal  tube.  The  illumination  is  supplied  by  the  well-known 
Caspar  electroscope  (C).  The  longest  tubes  enable  one  to  reach  the 
sigmoid  flexure.  The  field  of  vision  is  kept  clear  of  mucous  frag- 
ments or  fseces  by  cotton  applicators  20  and  35  centimetres  long. 
To  facilitate  the  introduction  of  this  instrument  I  have  had  the 
obturators  made  conical,  and  in  order  to  determine  which  portion  of 


THE  EXAMINATION   OF   THE   PATIENT 


81 


the  rectum  the  speculum  has  reached  I  have  had  a  centimetre  scale 
marked  upon  the  tubes. 

Inspection  of  the  rectum,  in  the  first  place,  enables  one  to  detect 
acute  and  chronic  inflammations  of  the  mucous  membrane.  In 
acute  cases  the  mucous  membrane  has  not  the  normal  pale  appear- 
ance, but  appears  swollen  and  strongly  injected ;  in  chronic  inflam- 


FlG.    11. 

mations  it  appears  relaxed,  swollen,  and  velvety,  is  covered  with  firm 
mucus,  and  easily  bleeds.  With  good  illumination  the  follicular 
swellings  become  distinctly  visible.  In  well-pronounced  cases,  a 
muco-purulent  secretion  trickles  over  the  surface.  As  a  rule,  these 
inflammations  are  not  primary,  but  occur  in  connection  with  other 
rectal  diseases.  Furthermore,  on  inspection  one  can  distinctly  see 
ulcerations  (fsecal,  dysenteric,  tubercular,  gonorrhoeal,  hemorrhoidal, 
syphilitic,  etc.),  and,  in  children,  follicular  ulcers,  When  typically 
developed,  these  different  forms  can  be  distinguished  from  one  an- 
other. Rectal  fistulse  (internal  and  external),  hemorrhoidal  veins, 
polyps  and  other  growths,  strictures,  etc.,  can  also  be  seen.  Since 
these  various  affections  are  treated  of  at  length  in  the  second  por- 
tion of  this  work,  we  may  here  content  ourselves  with  this  brief 
reference  to  the  subject. 

By  bougieing  of  the  rectum  and  of  the  parts  above,  we  may 
sometimes  learn  whether  or  not  that  gut  and  the  sigmoid  flexure 
are  patent.  For  this  purpose  we  employ  either  soft-rubber  bougies,* 
or  else  the  so-called  English  [known  here  in  the  United  States  as  the 
French  sounds]  or  hard-rubber  bougies,  or,  finally,  though  more 


*  Those  with  a  spiral  obturator,  as  devised  by  Haha,  are  particularly  good,  be- 
cause they  combine  great  elasticity  with  firmness. 


82  DISEASES   OF   THE  INTESTINES 

rarely,  the  so-called  Trousseau's  sounds,  with  olive-shaped  ivory 
points  that  can  be  screwed  on  and  off.  The  softer  the  iustrament 
employed  for  diagnostic  purposes  the  less  the  danger.  When 
sounding  the  rectum  for  the  first  time,  I  use  only  soft-ruljber 
sounds  or  bougies.  The  question  how  far  a  bougie  may  be  intro- 
duced is  very  important.  Some  authorities  state  that  it  can  not  be 
passed  beyond  the  sigmoid  flexure.  According  to  my  own  investi- 
gations this  is  incorrect,  for  by  abdominal  palpation  of  sounds  which 
1  had  introduced  I  have  been  convinced  that,  if  the  colon  be  pre- 
viously distended  by  water  or  air,  even  soft  J^elaton  sounds  can  be 
passed  into  the  descending  colon.  I  purposely  employ  the  word 
caw,  for  our  success  depends  principally  upon  the  sound  passing 
through  ]S"elaton's  sphincter  into  the  sigmoid  flexure.  In  some 
cases  this  is  accomplished  very  readily,  in  others  only  by  the  aid  of 
one  or  two  fingers  in  the  rectum  acting  as  a  guide  to  the  instru- 
ment. Should  this  last  precaution  be  neglected,  flexible  instru- 
ments curl  up  in  the  wide  ampulla  or  impinge  against  its  walls, 
thus  making  forward  passage  impossible.  On  account  of  the  acute 
bend  which  the  splenic  flexure  makes  at  the  junction  of  both  seg- 
ments of  the  colon,  passage  into  the  transverse  colon,  on  the  con- 
trary, is  impossible. 

Bougies  and  sounds  should  be  thoroughly  oiled  before  intro- 
duction ;  the  latter  procedure  must  be  attended  by  the  greatest 
precaution.  All  force  must  be  carefully  avoided.  This  rule  ap- 
plies particularly  to  all  sounds  which  are  not  absolutely  soft,  for 
during  simple  sounding  of  the  normal  rectum  perforations  have 
occurred. 

The  diagnostic  value  of  rectal  bougieing  is  not  great.  We  can 
not  learn  more  from  bougieing,  at  least  of  the  rectum,  than  we  can 
from  digital  and  ocular  examinations.  On  the  other  hand,  only 
through  sounding  can  constrictions  of  the  sigmoid  flexure  or  of  the 
descending  colon  be  diagnosed  with  certainty.  Such  examinations, 
however,  require  the  greatest  possible  care,  and  I  would  again  recall 
the  advantages  of  the  above-mentioned  rubber  bougies.*  A  stric- 
ture can  he  diagnosticated  with  certainty  only  when,  npon  rejpeated 
examinations,  the  passage  of  a  sound  itnparts  the  impression  of  its 

*  Kuhn,  of  Giessen,  recently  devised  metallic  spiral  sounds  for  the  sounding 
of  the  stomach,  pylorus,  duodenum,  and  the  large  intestine.  From  these  sounds 
he  hopes  to  learn  much  of  value  for  the  diagnosis  and  therapeutics  of  the  said  organs. 
Since  no  evidences  of  the  merits  of  this  method  have  as  yet  been  advanced,  we  wiU 
not  discuss  it,  nor  the  method  of  Hemmeter  for  the  intubation  of  the  duodenum. 


THE  EXAMINATION  OF  THE   PATIENT  83 

always  having  to  overcome  a  resistance  at  the  same  jpoint,  and 
when,  after  the  suspicious  point  is  passed,  the  withdrawal  of  the 
sound  also  gives  one  the  iinpression  of  passage  through  a  narrow 
portion. 

Aside  from  diagnostic  purposes,  rectal  bougies  are  also  em- 
ployed for  the  dilatation  of  strictures.  This  will  be  referred  to  in 
the  proper  place  in  the  second  portion  of  this  work. 

3.  Percussion 

In  general,  percussion  gives  us  less  tangible  results  than  palpa- 
tion. ISTevertheless  it  is  of  value  as  completing  and  controlling  the 
latter  procedure,  and  it  should  therefore  never  be  omitted. 

Percussion  of  the  intestines  should  always  be  finger  percussion, 
never  hammer  percussion,  for  with  the  latter  finer  distinctions  are 
very  easily  overlooked.  We  should  always  percuss  lightly,  for 
then  only,  if  at  all,  can  differences  in  tone  be  clearly  brought  out. 
In  the  empty  state  of  the  intestines  percussion  gives  the  best 
results.  It  is  sometimes  of  importance  to  compare  the  result  of 
percussion  of  the  empty  with  that  of  the  full  intestines  (and  stom- 
ach). I^ormally,  as  in  the  stomach,  the  percussion  note  is  tym- 
panitic, but  varies  in  pitch  in  the  different  segments.  On  account 
of  the  descending  colon  being  filled  with  solid  matter,  palpatory 
percussion,  according  to  Leo  ^^,  almost  constantly  gives  a  dull  tym- 
panitic tone  in  the  left  hypochondrium  as  compared  to  that  obtained 
on  the  right  side.  The  diagnostic  value  of  percussion  is  limited  to 
those  cases  in  which  we  find  distinct  variations  from  the  normal 
tone.  This  occurs  with  free  or  encapsulated  fluids  in  the  abdomi- 
nal cavity,  and  also  in  excessive  meteorism.  The  results  from  per- 
cussion in  ascites  ai-e  so  well  known  that  detailed  discussion  is 
unnecessary.  We  wish,  however,  to  speak  of  the  differentiation  of 
air  in  the  abdominal  cavity  from  that  in  the  intestines.  Whereas 
in  the  former  instance  the  percussion  note  has  everywhere  a  uni- 
formly tympanitic  sound,  and  hepatic  and  splenic  dulness  disappear, 
in  intestinal  meteorism  the  percussion  note  varies  from  place  to 
place  and  from  time  to  time. 

The  percussion  note  over  large  tumours  of  the  intestines  (includ- 
ing fsecal  tumours)  is  flat,  provided  they  are  not  covered  by  intes- 
tinal coils  that  contain  air.  In  the  presence  of  moderate  amounts 
of  fluid  in  the  abdomen,  tumour  percussion  in  various  postures  of 
the  patient  may  also  yield  useful  results.  If  the  abdomen  be  tapped 
before  percussion  the  results  will  naturally  be  more  satisfactory. 


34  DISEASES   OF   THE   INTESTINES 

By  filling  the  intestines  with  air  or  water  we  can  establish  condi- 
tions favourable  to  percussion  (see  pages  74  and  85). 

In  ileus,  in  order  to  distinguish  between  widely  distended  intes- 
tinal coils  and  those  of  smaller  calibre,  a  few  authors,  particularly 
Curschmann  ^^,  have  recommended  pleximeter  percussion, 

4.   Auscultation 

Of  all  physical  methods  of  examination,  auscultation  has  the 
least  diagnostic  value.  It  is  true  that  sounds  (borborygmi,  gur- 
gling, etc.)  are  heard  in  the  most  varied  diseases  of  the  intestines, 
but  the  nature  of  their  production  is  so  atypical  that  little  can  be 
learned  from  them.  In  stenosis  of  the  large  intestines  we  meet 
with  intestinal  sounds  (especially  frequently  recurring  intestinal 
sounds)  on  a  most  extensive  scale,  but  compared  with  the  data 
obtained  from  palpation,  or  even  inspection,  their  diagnostic  value  is 
minimal.  On  the  other  hand,  the  absence  of  all  intestinal  sounds, 
together  with  total  absence  of  all  intestinal  movements,  is  of  diag- 
nostic value  in  perforative  peritonitis  (E.  Wagner  ^^ ). 

The  well-known  ileo-csecal  gurgling  of  typhoid  fever  to-day 
p)Ossesses  an  historical  value  only.  All  experienced  physicians 
agree  that  it  has  no  practical  value.  Kegarding  succussion  and 
splashing  sounds,  compare  above  (page  73). 

5.   Inflation  of  tine  Intestines 

Inflation  of  the  intestines  can  be  accomplished  either  through 
the  introduction  of  mixtures  which  form  carbonic-acid  gas  (bicar- 
bonate of  soda  and  tartaric  acid,  von  Ziemssen  " ),  or  of  carbonic- 
acid  gas  from  fluids  in  retainers  (O.  Rosenbach  ^^ ),  or  else  from 
inverted  siphons  of  carbonic-acid  gas  ^^,  or  finally  through  the  intro- 
duction of  atmospheric  air  by  means  of  a  double  balloon  bulb,  such 
as  is  used  with  a  spray  apparatus  (E-uneberg  ^° ).  Of  all  these  meth- 
ods the  last  mentioned  is  certainly  the  simplest  and  best ;  we  can 
inflate  the  intestines  with  as  much  or  as  little  air  as  we  wish. 
Should  there  be  any  occasion  for  measuring  the  amount  of  air 
introduced,  we  may  employ  a  syringe  of  known  volume  and  intro- 
duce the  air  from  this  (Damsch  ^^ ). 

How  far  can  the  air  be  introduced  ?  Most  authors,  particu- 
larly von  Ziemssen  and  O.  Rosenbach,  claim  that  the  air  can  not 
pass  beyond  the  ileo-csecal  valve ;  whereas  Damsch  has  shown  that 
with  slow  inflation  and  the  employment  of  more  than  one  metre 
of  air,  the  valve  may  be  overcome  and  even  the  small  intestines 


THE   EXAMINATION   OF   THE   PATIENT  85 

inflated.  In  view  of  similar  successful  attempts  made  with  large 
quantities  of  water  (von  Genersich^^)  we  must  at  once  admit  the 
possibility  of  overcoming  the  resistance  of  the  valve  with  air. 
Both  methods  are  very  heroic,  and  have,  besides,  no  advantage  over 
the  introduction  of  small  quantities  of  air  or  water. 

Upon  the  whole,  therefore,  we  shall  have  to  remember  that,  as 
ordinarily  practised,  the  introduction  of  air  distends  the  large  intes- 
tine only. 

The  technic  of  rectal  inflation  is  very  simple.  For  this  pur- 
pose a  soft  stomach  or  i-ectal  tube,  or,  in  case  of  necessity,  even  the 
rubber  tube  of  an  irrigator,  may  be  used.  A  well  functionating 
double  balloon  bulb  is  attached  to  the  tube.  Before  introducing 
the  rubber  tube  we  must  see  whether  there  is  much  faecal  matter 
in  the  rectum  ;  if  so,  it  must  be  removed.  Small  quantities  of  fseces 
need  not  be  taken  into  account.  To  learn  if  air  passes  into  the 
intestines,  we  should  auscultate  in  the  left  iliac  region ;  a  hissing 
sound  made  by  the  entering  air  can  here  be  distinctly  heard.  Prac- 
tically it  is  very  iinportant  not  to  inflate  the  intestines  too  greatly, 
for  finer  shades  of  difference  in  sound  are  best  apj)reciated  with 
slight  inflation.  It  is  often  useful  to  combine  inflation  of  the  stom- 
ach with  that  of  the  intestine. 

Inflation  of  the  intestines  has  a  threefold  practical  diagnostic 
signification  ;  it  enables  us  to  diagnose  stenoses  with  a  certain 
amount  of  probability,  sometimes  even  with  certainty ;  further- 
more, it  makes  clear  displacements  of  the  intestines,  especially  of 
the  movable  portions ;  finally,  it  is  of  value  in  locating  tumours  and 
in  determining  their  mobility. 

Regarding  the  diagnosis  of  stenoses,  we  may  remark  that  nor- 
mally, in  compliance  with  physical  laws,  the  entire  large  intestine 
forms  a  uniform  prominence ;  in  stenosis  of  a  segment  the  infra- 
stenotic  portion  only  can  be  inflated,  and  will  therefore  appear  more 
prominent,  while  the  supra-stenotic  portion  will  be  very  little  or  not 
at  all  distended.  Furthermore,  if  the  inflation  be  continued,  the 
air  will  return  and  pass  out  per  anum  alongside  of  the  tube,  and 
severe  pain  will  be  apt  to  follow.  The  results  obtained  from  per- 
cussion in  intestinal  stenoses  are  also  important ;  while  we  still  have 
the  usual  tympanitic  sound  above  the  stenosis,  we  will  get  a  deeper 
and  more  sonorous  one  below  it,  and  after  all  the  air  has  passed 
out  both  sounds  will  again  be  uniform.  When  the  inflated  air 
presses  upon  the  stenosed  parts  it  is  sometimes  possible  to  hear  a 
peculiar  long-drawn  sound  that  may  also  be  of  diagnostic  value. 
7 


86  DISEASES  OF  THE  INTESTINES 

Great  as  may  be  the  value  of  this  method,  for  the  development 
of  which  much  credit  is  due  to  von  Ziemssen,  it  should  nevertheless 
be  remarked  that  reliable  results  are  obtained  therefrom  only  in 
very  marked  stenoses.  In  these  cases,  however,  the  other  symp- 
toms of  intestinal  obstruction  are  so  well  characterized,  that,  after 
all,  intestinal  inflation  should  be  employed  mainly  as  a  confirma- 
tory method.  For  obvious  reasons  it  frequently  gives  negative 
results  in  the  beginning  of  a  stenosis. 

A  further  advantage  of  the  method  lies  in  the  possibility  of 
diagnosticating,  with  more  or  less  certainty,  changes  in  the  position 
of  various  segments  of  the  large  intestine.  If,  for  examj)le,  after 
moderate  distention  of  the  large  intestine  a  transverse  protrusion 
is  seen  below  the  umbilicus,  or  even  immediately  above  the  sym- 
physis, and  the  same  result  obtains  after  repeated  examinations,  we 
are  safe  in  assuming  that  a  sinking  of  the  transverse  colon  {colojjto- 
sis)  has  taken  place.  The  sigmoid  flexure  sometimes  becomes  en- 
larged or  dislocated,  or  both,  so  that  the  greatest  difficulty  may  be 
experienced  in  differentiating  it  from  the  transverse  colon. 

Finally,  as  is  well  known,  in  inflation  of  the  intestines  we  have 
a  means  of  ascertaining  with  certainty  the  position  of  questionable 
intestinal  tumours,  and  of  distinguishing  between  these  and  tumours 
of  other  organs  (e.  g.  the  kidney),  since  the  latter  disappear  gradu- 
ally with  inflation,  whereas  the  former  (tumours  of  the  intestine)  re- 
main as  perceptible  as  before.  J^evertheless,  this  symptom  can 
only  be  taken  into  account  where  a  tumour  previously  perceptible 
completely  disappears.  In  like  manner  intestinal  tumours  may  fre- 
quently be  very  clearly  differentiated  from  those  of  the  liver. 

6.  The  Injection  of  Water  per  Anum 

The  injection  of  water  per  antinn  is  principally  employed  to 
locate  an  intestinal  stenosis  (Simon),  or  to  establish  the  relation  of  a 
new  growth  to  surrounding  organs  (Minkowski  ^^).  In  the  latter 
case  it  is  well  to  combine  the  procedure  with  inflation  of  the 
stomach. 

,  Here,  according  to  Minkowski,  the  abdominal  tumour  slips  back 
into  the  position  normally  occupied  by  the  organ  to  which  it  be- 
longs. Here,  also,  it  is  frequently  well  to  combine  the  distention 
of  the  stomach  by  air  or  water  with  similar  distention  of  the  large 
intestine.  The  recognition  by  means  of  distention  of  a  stenosis — 
especially  one  occurring  far  down — is  based  upon  the  fact  that 
under  normal  conditions  2  to  5  (!)  litres  can  be  passed  into  the  intes- 


THE   EXAMINATION   OF   THE   PATIENT  8Y 

tines,  whereas  in  deep  stenosis  very  much  less  can  be  introduced. 
This  method  is  unreliable  if  for  no  other  reason  than  because  the 
toleration  of  the  rectum  for  quantities  of  water  varies  considerably 
(at  least  according  to  my  experience).  The  water  is  introduced  by 
means  of  an  irrigator  armed  with  a  calibrated  tube  or  else  by  means 
of  a  Hegar's  funnel. 

7.  Test  Lavage  of  the  Intestines 2* 

By  this  I  mean  a  uniform  irrigation  of  the  mucous  membrane 
of  the  entire  large  intestine  with  water,  for  the  purpose  of  recog- 
nising anomalies  of  the  same  (mucus,  pus,  blood,  or  even  fragments 
of  tumours)  in  the  returning  water. 

Technic. — The  following  rules  are  given  for  test  lavage  of  the 
intestine.  It  is  best  carried  out  with  the  patient  in  the  lateral  posi- 
tion, the  intestines  being  previously  emptied.  1  use  a  soft-rubber 
tube,  not  too  small  in  calibre,  and  from  about  70  to  80  centimetres 
in  length,  armed,  as  in  lavage  of  the  stomach,  with  rubber  tubing 
and  a  large  funnel.  The  tube  is  well  greased,  and  after  its  intro- 
duction into  the  anus  is  gradually  pushed  forward,  while  the  funnel, 
filled  with  lukewarm  water,  is  at  the  same  time  slowly  raised.  In 
suitable  cases — as  can  be  proved  by  palpation  through  the  abdom- 
inal wall — we  are  sometimes  able  to  introduce  the  tube  into  the  sig- 
moid flexure,  or  even  beyond.  As  soon  as  marked  tenesmus  occurs 
(not  infrequently  after  more  than  a  half  litre  has  been  introduced) 
the  funnel  should  be  lowered,  and  the  water  thus  siphoned  off  should 
be  carefully  inspected  and  preserved  in  clean  vessels  for  macroscopic 
and  microscopic  examination.  I^ormally,  the  water  returns  clear, 
or  only  slightly  cloudy  from  admixture  of  very  minute  particles  of 
mucus,  epithelium,  or  small  particles  of  faeces.  It  is  very  differ- 
ent, for  example,  in  catarrh  of  the  large  intestine.  Here  the  wash 
water  to  a  greater  or  less  extent  contains  large  and  small  shreds 
of  mucus.  Their  quantity  serves  as  a  good  criterion  of  the  progress 
and  the  extent  of  the  disease.  We  have  no  simple  or  easier  method 
than  this  for  diagnosticating  membranous  enteritis.  This  proced- 
ure, which  I  have  used  for  a  long  time,  has  also  given  me  excel- 
lent results  in  detecting  suppurative  and  ulcerative  processes  accom- 
panied by  haemorrhage.  I  have  often  found  pieces  of  exfoliated 
mucous  membrane  in  the  wash  water,  and  though  I  can  not  speak 
from  personal  experience,  it  apjDears  possible  to  readily  obtain  in  this 
manner  fragments  of  tumours  for  examination.  Where  it  is  desir- 
able to  make  a  microscopical  examination,  this  procedure  possesses 


88  DISEASES  OF  THE  INTESTINES 

the  advantage  of  absolute  cleanliness,  a  fact  which  is  very  advan- 
tageous considering  the  offensive  smell  of  faeces.  Besides,  the  isola- 
tion of  pathological  substances  (free  from  fgecal  matter)  makes  the 
microscopical  examination  much  easier. 

8.  Electric   Trans-illumination    of   the    Large    Intestines 

Herjng  and  Reichmann  ^  were  the  first  to  employ  diaphanos- 
cope for  the  determination  of  the  limits  of  the  large  intestine. 
They  used  a  black  elastic  intestinal  bougie,  to  the  end  of  which  a 
small  Edison  lamp  was  fastened.  Before  introducing  the  bougie, 
1,500  centimetres  of  lukewarm  water  were  poured  into  the  rectum. 
By  using  a  lamp  of  25  volt  amperes  (equal  to  eight  standard  candle 
power),  the  contour  and  course  of  the  transverse  colon  were  dis- 
tinctly mapped  out.  With  the  development  of  the  method,  Heryng 
and  Reichmann  hoped  it  would  be  possible  to  approximately  deter- 
mine doubtful  tumours  of  the  abdominal  cavity,  but  thus  far  this 
expectation  has  not  been  realized. 


APPENDIX 

The   Employment  of  Röntgen   Rays  in  the   Diagnosis  of 
Intestinal  Diseases 

Hitherto  the  results  in  general  from  skiagraphy  in  the  diagnosis 
of  abdominal  diseases  have  not  been  very  promising ;  especially  has 
it  been  impossible  to  positively  diagnosticate  abdominal  tumours 
that  could  not  also  be  diagnosed  by  the  usual  methods.  On  the 
other  hand,  the  location  of  metallic  foreign  bodies  in  the  large 
intestines  by  means  of  the  Röntgen  rays  appears  to  me  to  be  very 
plausible.  I  am  convinced  that  we  can  see  certain  portions  of  the 
large  intestine — e.  g.,  the  descending  colon — and  especially  dis- 
tinctly recognise  the  haustra  coli.  It  is  therefore  not  beyond  the 
limits  of  possibility  that  we  should  be  able  to  render  displacements 
of  the  intestines  visible  to  the  eye.  It  remains  to  be  seen  how 
much  more  favourable  conditions  will  be  created  through  the  intro- 
duction of  metalKc  sounds  and  the  like  into  the  rectum.  Since  the 
kidney  (particularly  the  left)  and  the  spleen  can  frequently  be  dis- 
tinctly recognised  by  the  fluoroscope,  it  might  be  possible,  under 
favourable  conditions,  to  make  the  differential  diagnosis  between 
tumours  of  the  kidney  and  of  the  intestine,  or  of  the  liver  and  the 
spleen. 


THE  EXAMINATION  OP   THE  PATIENT  §9 


LITERATURE 

1.  Nothnagel.     Die  Erkrankungen  des  Darnas  u.   des  Peritoneums.     Wien, 

1895,  S.  5. 

2.  Boas.     Verhandlungen  des  XV.  Congresses  f.  innere  Medicin,  1897,  S.  479. 

3.  Boas.     Diagnostik  u.  Therapie  der  Magenkrankheiten,  Th.  I,  4te  Aufl.,  1897, 

S.  71  u.  f. 

4.  Obrastzow.     Archiv  f.  Verdauungskrankheiten,  Bd.  i,  S.  263. 

5.  Edebohls.     Amer.  Journal  of  the  Medical  Sciences,  May,  1894. 

6.  Obrastzow.     Loc.  cit.,  p.  274. 

7.  Boas.     Loc.  cit.,  p.  105. 

8.  J.  Friedenwald.     Med.  News,  August,  1894. 

9.  Nothnagel.     Loc.  cit.,  p.  248. 

10.  Gersuny.     Wiener  klin.  Wochenschr.,  1896,  No.  40. 

11.  Hofmokl.     Wiener  med.  Wochenschr.,  1896,  No.  43. 

12.  Kelly.     Cited  from  Centralbl.  für  Chirurgie,  1895,  p.  961. 

13.  R.  Lewandowski.     Das  electrische  Licht  in  der  Heilkunde.     Wien  u.  Leip- 

zig, 1892,  S.  211. 

14.  Leo.     Diagnostik  d.  Krankheiten  der  Bauchorgane,  2.  Aufl.,  1895,  S.  109. 

15.  Curschmann.     Deutsch.  Archiv  f.  klin.  Med.,  Bd.  liii,  1894,  S.  30. 

16.  E.  Wagner.     Ibid.,  1886,  Bd.  xxxix,  S.  72. 

17.  von  Ziemssen.     Ibid.,  1883,  Bd.  xxxiii,  S.  235. 

18.  O.  Rosenbach.     Berl.  klin.  Wochenschr.,  1889,  No.  28. 

19.  Schnetter.     Deutsch.  Archiv  f.  klin.  Med.,  1884,  Bd.  xxxiv,  S.  638. 

20.  Runeberg.     Ibid.,  Bd.  xxxiv,  S.  460. 

21.  Darnsch.     Berl.  klin.  Wochenschr.,  1889,  No.  75. 

22.  von  Genersich.     Deutsche  med.  Wochenschr.,  1893,  No.  41. 

23.  Minkowski.     Berl.  klin.  Wochenschr.,  1888,  No.  31. 

24.  Boas.     Deutsch.  Aerzte  Zeitung,  1895,  No.  2  u.  3. 

25.  Heryng  u.  Reichmann.     Therapeut.  Monatshefte,  März  1892. 


CHAPTER  Y 

EXAMINATION  OF  THE  F^GES 

Preliminary  Remarhs. — The  examination  of  the  faeces  is  an 
integral  factor  in  the  diagnosis  of  intestinal  diseases.  We  learn 
from  it  pathological  changes  in  the  secretive,  absorptive,  and  motor 
functions  of  the  stomach  and  intestines,  and  ascertain  the  foreign 
substances  that  are  mingled  with  the  intestinal  contents.  Fre- 
quently also  the  nature  and  location  of  intestinal  diseases  can  thus 
only  be  correctly  appreciated  and  diagnosticated.  The  diagnosis  of 
entozoa  must  be  made  almost  entirely  from  the  microscopical 
examinations  of  the  dejections. 

In  spite  of  all  tliis,  we  are  safe  in  stating  that  even  at  the  pres- 
ent day  clinical  examination  of  the  faeces  is  not  universally  prac- 
tised. The  cause  for  this  is  very  clear.  In  the  first  place,  the  rejDul- 
sive  nature  of  the  material  itself,  so  disagreeable  to  the  olfactory 
nerves ;  then,  again,  the  unpleasant  manipulations  that  the  trans- 
port and  examination  of  the  material  entail  upon  the  layman  and 
the  physician ;  and  last,  but  not  least,  the  fact  that  faecal  exami- 
nations rarely  yield  decisive  diagnostic  results.  The  first  two 
objections  mentioned  are  undoubtedly  justifiable ;  the  latter  objec- 
tion is  also  valid  to  a  certain  degree.  But  the  principle,  sahis  mgroti 
2yrima  lex  esto,  should  help  us  to  overcome  all  hesitancy  and  diffi- 
culties. As  regards  the  diagnostic  value  of  faecal  examinations,  it 
must  be  admitted  that  a  single  examination  is  only  rarely  sufficient 
to  make  clear  the  nature  of  the  disease.  Still,  this  applies  equally 
well  to  all  other  secretions  and  excretions — e.  g.,  sputum,  stomach 
contents,  urine,  and  vaginal  secretions. 

In  clinics  and  dispensaries  the  facilities  for  macroscopical  and 
microscopical  examination  of  the  faeces  are  usually  very  easily 
arranged.  In  private  practice,  on  the  contrary,  it  is  usually  best 
to  make  the  first  gross  examination  in  the  dwelling  of  the  patient. 
Should  we  find  anything  unusual,  or  should  we  for  any  other  rea- 
son wish  to  make  a  microscopical  examination,  we  can  select  the 
90 


EXAMINATION   OF   THE   P^CBS  91 

parts  whicli  appear  pathological,  and  preserve  them  in  a  small  wide- 
mouthed  bottle  with  a  glass  stopper.  Only  where  exact  chemical 
analysis  (perhaps  for  nitrogen  or  fat)  is  required,  will  large  quanti- 
ties of  fgeces  be  necessary.  In  some  cases — for  instance  where  we 
suspect  amoebae — it  is  very  desirable  to  examine  the  faeces  fresh  and 
at  the  body  temperature,  if  possible.  This  is  readily  accomplished 
by  warming  the  bedpan  and  bringing  the  material  into  a  bottle,  also 
warmed,  and  wrapped  for  safety's  sake  in  cotton.  If  we  have  an 
incubator  we  can  place  the  material  in  it  until  we  are  ready  to  make 
the  examination,  otherwise  some  artificial  means  for  maintaining  the 
warmth  of  the  faeces  can  easily  be  devised.  In  some  cases  it  is  inter- 
esting to  follow  the  development  of  gases  from  thin  stools  placed  in 
a  warm  atmosphere,  and  to  note  the  influence  exerted  by  certain 
internal  medication  upon  such  gaseous  formation.  For  this  pur- 
pose we  may  use  the  so  called  "fermentation  tubes"  of  Einhorn 
and  Fiebig,  such  as  are  also  used  in  determining  the  gases  of  the 
stomach  contents.  Should  we  have  to  deal  with  ulcerative  processes 
of  the  rectum,  we  can  obtain  the  secretion  directly  upon  a  glass  rod 
or  a  platinum  loop — best  with  the  use  of  a  speculum  and  good  illu- 
mination. 

From  what  has  been  said,  it  will  be  readily  seen  that  the  exami- 
nation of  the  fgeces  is  divisible  into  the  macroscopical,  the  micro- 
scopical, and  the  chemical. 


1 .  The   Macroscopical    Examination 

In  the  last  chapter  a  few  striking  changes  were  briefly  men- 
tioned and  their  diagnostic  importance  dwelt  upon.  This  was 
necessary  because,  notwithstanding  the  best  intentions,  we  can  not 
at  the  time  of  the  first  consultation  always  obtain  test  material,  and 
for  the  time  being  are  compelled  to  rely  upon  the  statements  of  the 
patient.  In  the  following  discussion  it  is  intended  to  give  as  com- 
plete a  review  as  possible  of  the  macroscopical  changes  of  the  stools. 
Consistency  and  form,  appearance,  quantity,  colour,  smell,  as  well  as 
abnormal  ingredients,  will  have  to  be  considered. 

]^ormally,  the  f^ces  are  cylindrical  in  form,  with  great  variations 
in  the  calibre  of  the  individual  cylinders,  or  else  they  are  homoge- 
neous, and  of  a  thick,  pasty  consistency.  This  difference  in  con- 
sistency depends,  among  other  things,  upon  the  mode  of  life  of  the 
individual  and  upon  the  nature  of  the  diet.  Under  certain  condi- 
tions variations  from  the  types  just  mentioned  may  still  be  normal. 


92  DISEASES   OF   THE  INTESTINES 

This  fact,  often  overlooked,  is  of  great  practical  importance.  The 
following  will  serve  as  an  example  :  A  patient  who  has  just  passed 
through  typhoid  fever  is  constipated.  The  evacuations  occur  only 
after  enemata,  and  resemble  the  normal  faeces  of  the  sheep  ("  schaf- 
kothartig").  In  view  of  the  careful  diet  of  reconvalescence,  and 
the  lack  of  exercise  which  is  necessarily  associated  with  a  cured  case 
of  typhoid,  such  a  condition  of  the  stools  is  entirely  physiological, 
and  it  would  be  a  mistake  to  speak  here  of  atony  of  the  intestines 
following  typhoid.  Cases  like  this  occur  almost  daily,  and  where 
constipation  and  changes  of  the  stool  are  complained  of,  it  behooves 
the  physician  to  inquire  carefully  into  the  manner  of  living,  and 
above  all  into  the  diet  of  the  patient.  Conversely,  the  occurrence 
of  diarrhoea  with  a  diet  consisting  for  the  most  part  of  milk  or  of 
milk  preparations,  or  after  unaccustomed  drinking  of  sour  wines  or 
partaking  of  too  much  fruit  or  sweets,  is  an  entirely  normal  condition. 

Since  we  have  frequently  observed  false  therapeutic  measures 
instituted  because  of  a  failure  to  properly  recognise  the  conditions 
in  question,  we  believe  it  best  to  state  these  facts,  which,  without 
doubt,  are  known  to  the  experienced  physician.  Variations  in  con- 
sistency admit  of  two  possibilities :  the  stool  may  either  be  abnor- 
mally hard  and  passed  in  small  lumps  (scybala,  "  sheep  stool," 
"  hazel-nut "  stool),  or  in  long,  thin  cylinders ;  secondly,  the  opposite 
condition  may  occur — the  stools  are  passed  in  a  thin,  pasty,  or  even 
fluid  state. 

Yery  hard  faeces  with  occasional  furrows  (evidently  impressions 
from  the  tgenise  coli)  indicate  only  long  retention  within  the  intes- 
tine, and  consequent  desiccation.  Such  an  appearance  speaks  for 
intestinal  stricture  as  little  as  does  the  so-called  lead-pencil  stool. 
In  these  cases  there  are,  very  probably,  spastic  contj-actions  of  the 
intestines,  such  as  are  often  observed  in  chronic  constipation.  I 
would  lay  more  stress,  however,  upon  a  different  form  of  stool, 
which  I  have  frequently  seen  in  stenoses  of  the  intestine.  This 
consists  of  a  homogeneous,  thick,  pasty,  or  curdlike  evacuation,  in 
which  several  short  cylinders,  of  the  thickness  of  the  small  finger, 
float  about.  The  diagnostic  importance  of  this  stool  formation  must 
not  be  overestimated,  and  only  repeated  observation  of  the  same 
condition  is  of  significance. 

Thin  stools  may  also  vary  in  two  ways  :  they  may  be  very  watery, 
as  in  cholera  nostras,  or  asiatica,  or  they  may  have  a  certain  admix- 
ture of  mucus,  which  can  be  easily  recognised,  since  it  clings 
to  the  sides  of  the  glass  when  the  contents  are  poured  out.     The 


EXAMINATION   OF   THE   F.EOES  93 

microscopical  and  chemical  examinations  confirm  the  presence  of 
mucus. 

The  quantity  of  stool  passed  is  seldom  of  any  practical  impor- 
tance. In  stools  of  firm  consistency  the  quantity  voided  is  impor- 
tant, if  it  remain  considerably  below  the  normal.  It  should  be 
remarked,  however,  that  depending  upon  the  nature  of  the  diet 
(vegetable,  animal,  mixed,  milk,  soup,  starvation,  etc.)  the  greatest 
variations  occur.  There  may  be  repeated  small  watery  evacuations, 
accompanied  by  marked  tenesmus.  Such  evacuations  indicate  in- 
flammatory processes  in  the  lowermost  segments  of  the  intestine. 
Among  other  conditions,  stools  of  this  kind  occur  very  frequently 
with  haemorrhoids,  in  acute  and  chronic  dysentery,  proctitis,  inflam- 
mations of  the  prostate,  rectal  carcinoma,  etc. 

The  colour  of  the  fseces  bears  a  certain  relation  to  the  con- 
sistency. Even  the  normal  colour  may  show  variations ;  thus  in 
purely  meat  diet  it  is  dark  brown  (from  hseraatin  and  ferrous  sul- 
phate) ;  in  a  mixed  and  vegetable  diet,  although  much  lighter,  it  is 
still  brown  from  urobilin  (according  to  Fleischer^,  also  hilijprasin)  \ 
it  is  lightest  of  all  where  the  diet  consists  mainly  of  milk.  The 
longer  the  stool  remains  in  the  intestines  the  firmer  will  be  its  con- 
sistency  and  the  darker  its  colour.  Under  these  conditions  it  may 
even  assume  a  tarlike  appearance,  which  I  know  has  led  inexperi- 
enced persons  to  believe  there  have  been  gastric  or  intestinal  haem- 
orrhages. Where  the  intestinal  contents  pass  rapidly  through  the 
canal,  bilirubin  may  appear  unaltered  in  the  stools ;  in  fact,  some 
stools  give  bilirubin  reaction  only.  As  a  result  of  the  absence  of 
reduction  of  the  bile  pigments,  we  frequently  find  unaltered  bile 
pigments  in  children's  stools.  In  itself,  a  green  colouration  of 
stools  is  by  no  means  indicative  of  bilirubin,  for  substances  contain- 
ing chlorophyl,  when  partaken  of  in  large  amounts,  colour  the 
faeces  green.  Besides  these,  there  are  other  alimentary  colour 
changes  in  the  stool  that  are  not  without  practical  significance. 
Thus  the  stools  are  coloured  more  or  less  of  a  brownish  red  by 
cocoa,  a  dark  brown  with  a  shade  of  green  by  huckleberries  and 
preparations  containing  them,  and  also,  though  not  so  intensely,  by 
red  wine.  Iron  and  manganese  salts  give  to  the  stools  a  darker 
shade  than  they  ordinarily  have.  According  to  Quincke^,  in  this 
case  the  iron  is  not  converted  into  a  sulphate,  but,  owing  no  doubt 
to  the  action  of  intestinal  bacteria,  the  iron  salts  ai"e  reduced  to  iron 
oxydyl.  Similarly,  bismuth  colours  the  stools  very  darkly,  though 
by  no  means  a  jet  black.     As  Quincke  has  recently  shown,  and  as  I 


94  DISEASES  OP  THE  INTESTINES 

have  been  able  to  confirm  through  numerous  control  observations, 
the  cause  of  this  is  not  the  formation  of  bismuth  sulphate,  but,  like 
the  iron,  the  bismuth  is  reduced  to  bismuth  oxydyl.  Calomel  fre- 
quently, though  by  no  means  always,  imparts  a  greenish  tinge  to  the 
stool.  According  to  examinations  of  Hoppe-Seyler  and  Wassiljeff, 
this  results  from  a  reduction  of  a  portion  of  the  bilirubin  to  urobilin. 
The  anti-fermentative  action  of  the  calomel  depends  apparently  upon 
this  change.  Besides  the  drugs  mentioned  there  are  many  others 
which  also  cause  colour  changes  in  the  stools ;  thus  senna,  santonin, 
gamboge,  rhubarb  and  its  preparations,  colour  the  stools  yellowish. 

Acholic  stools  are  very  characteristic,  and,  in  view  of  the  phenom- 
ena attending  their  appearance,  can  not  fail  to  be  recognised.  Owing 
to  their  importance  they  will  be  considered  in  a  separate  section,  to 
which  the  reader  is  referred  (see  page  103). 

The  normal  odour  of  the  stool  results  from  the  presence  of  ska- 
tol,  and  to  a  lesser  degree  also  of  indol.  Under  pathological  con- 
ditions the  odour  depends  largely  upon  the  nature  of  the  sickness, 
and,  furthermore,  upon  the  length  of  time  that  the  faeces  have  re- 
mained within  the  intestinal  canal.  As  a  rule,  the  longer  they  stag- 
nate in  the  large  intestine  the  stronger  will  be  the  f secal  odour ; 
conversely,  after  a  rapid  passage  the  odour  may  be  very  slight  or  en- 
tirely absent.  The  rice-water  stools  of  cholera  asiatica  and  nostras 
are  the  best  examples  of  the  last-mentioned  condition.  In  very 
acute  intestinal  catarrhs  and  dysentery  the  odour  may  be  very 
slight  or  entirely  absent.  In  chronic  catarrh  of  the  small  intestines, 
too,  I  have  noticed  entire  absence  of  any  odour.  The  stools  of 
nursing  babies  often  have  a  sour  and  slightly  fsecal  smell.  The 
evacuations  of  adults  containing  large  amounts  of  fat,  particularly 
milk  fat,  may  lack  the  fsecal  odour,  but  instead  take  on  an  offensive 
smell  like  fatty  acids  or  even  cheese.  In  amoebic  enteritis  the  faeces 
have  a  peculiar  gelatinlike  odour.  This  was  first  observed  by  Quincke 
and  Roos^,  and  later  confirmed  by  myself^. 

Closure  of  the  common  bile  duct  is  frequently  attended  by  obsti- 
nate constipation,  and,  as  a  consequence,  the  evacuations  smell  very 
strongly ;  this  condition,  however,  changes  upon  the  administration 
of  agents  which  increase  intestinal  peristalsis.  Fetid-smelling  evac- 
uations occur  in  ulcerating  carcinoma  of  the  large  intestine  or  of 
the  rectum,  etc. 

Ahnorinal  admixtures  in  the  stool  occur  very  frequently,  and  at 
times  may  constitute  invaluable  diagnostic  symptoms  of  the  existing 
intestinal  disease. 


EXAMINATION  OP   THE   F^CES  95 

Blood. — Fresh  unclotted  blood,  when  mixed  with  the  stool,  must 
come  from  the  lower  portion  of  the  intestines.  It  will  require  local 
examination  of  the  rectum  or  lavage  of  the  large  intestines  to 
determine  its  exact  source.  Blood  may  also  appear  altered  and 
decomposed,  and  impart  a  colour  of  tar  or  wagon  grease  to  the  evac- 
uations. We  have  already  stated  what  is  most  important  in  this 
connection  on  page  64. 

Pu8. — Pus  may  appear  with  the  dejections  and  be  recognised 
by  the  naked  eye.  It  almost  invariably  comes  from  the  lower  por- 
tion of  the  intestines,  for  pus  from  the  higher  parts,  unless  voided 
in  very  large  quantities,  is  mixed  with  the  faeces,  and  undergoes 
physical  and  chemical  changes  which  make  it  macroscopically  and 
microscopically  unrecognisable. 

The  appearance  of  mucus  in  the  stools  is  of  special  importance. 
Its  significance  in  the  diagnosis  of  intestinal  diseases,  and  especially 
of  intestinal  catarrh,  has  been  taught  us  by  Nothnagel's  classical 
studies^.  Although  in  what  follows  I  base  my  remarks  mainly  on 
JSTothnagel's  teachings,  I  differ  with  this  clinician  in  a  number  of 
important  points,  and  shall  discuss  the  subject  in  the  light  of  my 
own  quite  extensive  experience.  In  the  first  place,  it  must  be 
remembered  that  in  itself  mucus  represents  a  normal  product,  inas- 
much as  it  is  always  possible  with  chemical  reagents  to  demon- 
strate its  presence  in  the  stools.*  The  mucus  covering,  which  is 
found  in  very  minute  quantities  partly  upon  the  surface  of  the 
faeces  and  partly  mingled  with  them,  is  also  a  normal  constituent, 
being  no  doubt  only  a  cohesive  agent.  Hence  I  can  not  indorse 
the  statement  of  ISTothnagel,  that  every  macro-  and  microscopically 
recognisable  admixture  of  mucas  with  the  stool  indicates  a  change 
from  the  actual  physiological  condition. 

Even  after  a  single  administration  of  an  active  cathartic  like 
castor  oil  we  frequently  find  a  large  amount  of  mucus  in  the 
evacuations.  We  can  not  here  speak  of  a  pathological  condi- 
tion. Furthermore,  we  know  that  there  is  a  physiological  or, 
more  properly  speaking,  alimentary  constipation  and  diarrhoea  (see 
above,  pages  95  and  96).  And  here  also  we  can  not  without 
definite  reason  regard  mucous  admixtures  in  the  stools  as  patho- 
logical. Apart  from  these  restrictions  ISTothnagel's  view  is  fully 
correct. 


*  On  the  other  hand,  Hoppe-Seyler's  view  that  the  main  ingredient  of  all  feces, 
normal  as  well  as  abnormal,  is  mucin,  is  certainly  not  correct. 


96  DISEASES   OF   THE  INTESTINES 

MacrosGOjoically  recognisable  mucns  appears  under  four  differ- 
ent forms : 

1.  As  pure,  thick  or  glistening  mucus  which  is  voided  as  such — 
i.  e.,  unmixed  with  the  faeces.  This  points  with  certainty  to  a  dis- 
eased condition  of  the  lowermost  segments  of  the  intestines — the 
rectum,  or,  at  most,  the  sigmoid  flexure.  It  should,  however,  be 
remembered  that  absence  of  such  mucus  does  not  at  all  speak 
against  catarrh  of  the  lower  intestinal  segments. 

2.  As  mucous  shreds,  or  membranes  with  or  without  amorphous 
mucous  masses,  indistinguishable  from  that  just  described.  It  occurs 
with  any  of  those  intestinal  aifections  so  frequently  referred  to, 
which  we  designate  as  membranous  enteritis ;  these  will  be  spoken 
of  more  in  detail  when  we  come  to  the  description  of  this  affection 
in  the  special  part  of  this  work. 

3.  As  tenacious,  sticky,  gummy,  brownish-yellow  mucus,  inti- 
mately mixed  with  thin  pasty  faeces.  If  stirred  with  a  glass  rod  it 
adheres  in  dense,  sticky  masses,  and  is  separated  from  the  basic 
mass  only  with  great  difficulty. 

4.  As  small  shreds  of  mucus  scarcely  macroscopically  visible. 
These  shreds  are  best  seen  by  shaking  up  the  fsecal  mass  in  a  glass 
vessel. 

With  the  exception  of  the  variety  that  accompanies  membranous 
enteritis,  and  which  at  times  develops  in  nervous  individuals  {colica 
mucosa^  Nothnagel),  all  the  other  forms  indicate  catarrh  of  the  large 
intestines. 

Although  for  years  I  have  carefully  looked  for  those  frog- 
spawn  or  sagolike  bodies  in  the  stool  whose  vegetable  origin  was 
first  recognised  by  Yirchow,  and  which  are  mentioned  by  l^oth- 
nagel  in  the  above  investigations,  I  have  thus  far  never  seen  them 
in  typical  form.  Kitagawa,  on  the  contrary,  thinks  that  sagolike 
bodies  of  mucous  character  are  met  with  in  enteritis  and  in  intes- 
tinal ulcers.  Research  into  this  matter  is  not  yet  concluded,  though 
if  for  no  other  reason  than  their  rarity  these  bodies  can  have  but 
slight  diagnostic  interest. 

Mucus  in  the  form  fisrt  observed  and  described  by  l^othnagel 
as  yellow  mucous  granules  is  barely  visible  macroscopically.  As 
described  by  this  author,  these  bodies  consist  of  yellow  or  brownish 
yellow  or  even  of  dark  green  granules  varying  in  size  from  poppy 
seeds  to  peas,  and  having  the  consistency  of  butter.  Microscopical 
and  micro-chemical  examinations  have  shown  that  their  colour  is 
due  to  unaltered  bilirubin,  and  it  can  be  readily  demonstrated  that 


EXAMINATION  OF  THE   F^CES  97 

the  ground  substance  of  tliese  bodies  consists  of  mucin  or  of  a  body 
similar  to  it.  According  to  JN^otlmagel,  these  bodies  point  to  catarrh 
of  the  small  intestines.  They  may  occur  in  the  stool  singly  or  in 
large  numbers.  Although  I  make  it  a  rule  to  examine  the  stools  in 
every  case  of  intestinal  catarrh,  I  have  never  seen  these  yellow 
mucous  granules.  One  of  our  best  authorities  upon  mucoid  bodies 
(Ad.  Schmidt)  also  questions  their  existence  and  their  diagnostic 
significance.  According  to  Nothnagel,  mucus  can  be  recognised 
by  the  microscope  exclusively,  only  under  the  following  condition : 
Where  the  faeces  are  formed,  are  of  a  firm  pasty  consistency,  and 
have  intimately  mixed  with  them  numerous  small  particles  of 
mucus,  which  appear  under  the  microscope  as  small  homogeneous, 
hyaline,  grayish-white  refractive  islets.  IS^othnagel  regards  their 
presence  as  indicative  of  a  catarrh  of  the  uppermost  portion  of 
the  large  or  of  the  lowermost  portion  of  the  small  intestine.  I 
have  never  seen  these  hyaline  mucous  "  islets "  of  !N^othnagel,  and 
Ad.  Schmidt^,  who  regards  them  as  dead  amcebse,  doubts  their  mu- 
cous structure.  At  all  events,  no  positive  diagnostic  importance 
can  be  attributed  to  their  presence  in  the  faeces. 

Important  as  is  the  appearance  of  mucus  in  the  stools  for  the 
diagnosis  and  location  of  a  catarrh,  its  absence  does  not,  as  I  have 
already  remarked,  exclude  catarrh.  For  example,  as  JSTothuagel 
mentions,  and  I,  too,  have  been  able  to  show  in  a  very  typical  case 
(see  Part  II,  Intestinal  Catarrh),  mucus  may  be  entirely  absent  in 
jejunitis.  Furthermore,  mucus  may  be  entirely  absent  in  intestinal 
atrophy — so-called  lienteritis  of  old  persons.  In  both  these  in- 
stances the  clinical  picture  is  so  ty]3ical  that  with  careful  observa- 
tion the  diagnosis  should  present  no  difficulties.  Undigested  food 
remnants  are  visible  in  the  faeces.  The  opinions  even  of  scientific- 
ally educated  and  experienced  physicians  differ  so  widely  regarding 
the  significance  of  this,  that  I  desire  to  state  my  own  views  on  the 
subject. 

Per  se  isolated  or  occasionally  macroscopically  recognisable 
food  remnants  in  the  faeces  do  not  indicate  disease,  for  they  may 
result  from  poor  preparation  of  the  food  or  from  insufficient  chew- 
ing ;  or  else,  owing  to  utter  insolubility,  these  remnants  may  have 
entirely  escaped  the  action  of  the  digestive  juices.  To  judge  from 
my  own  experience,  this  would  apply  almost  entirely  to  vegetable 
substances  (fruits,  potatoes,  legumes,  etc.).  Macroscopically  visible 
remnants  of  meat,  on  the  contrary,  point  to  a  serious  disturbance  in 
the  function  of  the  digestive  tract,  the  exact  location  being  only 


98  DISBASES  OF   THE  INTESTINES 

jjossible  through  the  entire  clinical  observation,  especially  in  com- 
bination with  the  examination  of  the  stomach  contents.* 

The  constant  appearance  of  large  amounts  of  the  above-named 
vegetables  in  the  faeces  points  with  great  probability  to  anomalies 
of  secretion  in  the  gastro-intestinal  canal.  In  particularly  severe 
cases  of  chronic  intestinal  catarrh  in  which  the  stomach,  as  a  rule, 


^ 


^ 
^ 


Fig.  12. — Spieals  of  undigested  AIeat  Fragments  in  F^ces.     (Natural  size.) 
J,  pieces  of  bronchi.     (Original  observation.) 

is  also  involve'},  we  may  regularly  find  large  amounts  of  undigested 
meat,  as  well  as  of  vegetables,  fruits,  etc.,  in  the  faeces.  These  sub- 
stances may  take  on  an  extraordinary  appearance,  such  as  shown  in 
Fig.  12,  drawn  from  a  fresh  specimen.  This  important  form  of 
enteritis  will  be  again  referred  to  in  the  special  part  of  this  work. 


*  [Recently,  in  a  very  interesting  and  instructive  paper,  A.  Schmidt  (Deutsche 
med.  Wochenschr.,  1899.  No.  49)  has  sought  to  formulate  the  principles  which 
govern  the  appearance  of  meat  remnants  in  the  faeces.     By  experiments  he  shows 


EXAMINATION  OF  THE   P^CES  99 

Occasionally,  fragments  of  new  growths  (polyps,  ulcerated  carci- 
noma, etc.)  are  seen,  although  their  appearance  in  the  faeces  is  usu- 
ally accidental.  As  is  well  known,  entozoa  (ascarides,  segments  of 
tapeworm,  oxyuris,  anchylostomum,  trichocephalus,  anguillula,  etc.) 
as  well  as  echinococcus  are  sometimes  also  found  in  the  stools.  The 
diagnostic  importance  of  these  bodies  requires  no  special  mention. 

2.  The  Chemical  Examination 

The  practical  object  of  this  book  prohibits  us  from  describing 
all  chemico-physiological  tests.  In  the  following,  therefore,  we 
treat  only  of  the  more  important  methods,  and  at  the  same  time 
shall  discuss  the  diagnostic  importance  of  each.     We  shall  consider 

1.  Reaction  of  the  Fjeces 

The  normal  reaction  of  the  faeces  is  neutral  or  slightly  alkaline, 
changing  to  feebly  acid  only  when  the  diet  is  largely  a  vegetable  one. 
The  reaction  becomes  very  strongly  acid  on  occlusion  of  the  flow  of 
bile  into  the  intestines,  being  principally  due  to  the  presence  of  fatty 
acids  which  have  been  incompletely  or  not  at  all  saponified.  The 
qualitative  test  of  the  reaction  of  the  stool  is  made  in  the  usual 
manner  with  litmus  paper.  It  should  be  remarked,  however,  that 
the  surface  of  the  faecal  masses  may  give  a  different  reaction  than 
the  inner  portions.  To  make  a  quantitative  determination,  20  to  50 
centimetres  are  mixed  in  a  mortar  with  about  ten  times  their  amount 
of  distilled  water,  and  a  few  drops  of  jL  Phenolphthalein  solution  or 
of  a  good  litmus  solution  are  added  as  an  indicator ;  or  litmus  paper 
itself  may  be  used  instead.  Decinormal  NaOH  or  decinormal 
Ba(0II)2  (Eubner)  are  added  drop  by  drop  until  a  neutral  reaction 

that  the  connective  tissue  is  digested  by  the  gastric  juice  and  the  muscle  fibres  and 
nuelein  by  the  pancreatic  juice.  The  ingestion  pro  die  of  about  100  grams  of 
finely  chopped  and  lightly  fried  beef  should  result  in  no  meat  remnants  in  the 
stools.     From  his  researches  Schmidt  concludes  : 

1.  That  the  appearance  under  such  circumstances  of  macroscopically  visible 
connective  tissue  (or  of  a  large  amount  under  a  free  diet)  indicates  some  disturb- 
ance of  gastric  function  (either  secretory,  i.  e.,  hyper-,  sub-,  or  anacidity,  or  else 
motory,  i.  e.,  hyper-  or  submotility). 

2.  If,  in  addition  to  the  connective  tissue,  there  are  also  macroscopically  visible 
muscle  fibres  present,  there  must  also  be  a  disturbance  of  intestinal  digestion. 

3.  If  visible  muscle  fibres  appear  without  any  connective  tissue,  there  must  be 
a  serious  disturbance  in  intestinal  digestion,  but  whether  dependent  upon 
anomalies  of  the  pancreatic  secretion  or  upon  interference  with  the  secretory  or 
absorptive  functions  of  the  intestine  itself,  it  is  impossible  to  state. — Tr.] 


100  DISEASES   OF   THE  INTESTINES 

is  obtained.  The  amount  of  alkaline  solution  added  to  obtain  neu- 
tralization can  be  expressed  in  percentage,  as  is  done  witli  the  stom- 
ach contents.  For  example,  if  it  requires  3  centimetres  to  neutralize 
50  grams  of  fresh  fseces,  the  percentage  acidity  of  the  latter  will 
be  equal  to  6  decinormal  ]^aOH.  Conversely,  the  alkalinity  may 
be  determined  in  suitable  cases  with  decinormal  HCl. 

As  Nothnagel  has  pointed  out,  no  diagnostic  significance  attaches 
itself  to  the  reaction  of  the  intestinal  evacuations. 

2.  Determination  of  Albuminoid  Bodies  in  the  Fjeces 

The  albuminoid  bodies  which  may  occur  in  the  faeces  are  mucin, 
albumin,  and  peptones  (albumoses). 

{a)  Determination  of  Mucin 

Either  the  fseces  themselves  or  some  mucoid  masses  mixed  with 
them  may  have  to  be  analyzed.  In  the  first  instance  the  fseces 
should  be  rubbed  up  with  water,  and  an  equal  volume  of  lime- 
water  added  ;  after  the  mixture  has  stood  for  several  hours  the 
filtrate  is  to  be  tested  for  mucin.  Where  mucoid  bodies  themselves 
are  to  be  analyzed,  they  should  first  be  dissolved  in  weak  potas- 
sium or  sodium-hydrate  solution  and  then  tested  with  acetic  acid. 
Insolubility  in  an  excess  of  the  acetic  acid  would  speak  for  mucin. 
To  avoid  confusion  with  mucinlike  nucleo-albumin,  the  precipitate 
must  be  further  tested  by  boiling  mth  dilute  mineral  acids. 
Should  a  substance  which  reduces  oxid  of  copper  be  readily  thrown 
do^vn,  the  precipitate  may  be  regarded  as  being  mucin.  It  must, 
however,  be  shown  that,  after  repeated  reprecipitation,  the  sub- 
stance in  Cjuestion  is  still  free  from  phosphorus. 

A  much  simpler  and  an  equally  effective  test,  in  my  opinion, 
is  the  macroscopical  staining  of  the  mucus  by  means  of  Ehrlich's 
triacid  solution.  A  small  piece  of  mucus  is  broken  up  in  sublimate 
alcohol  and  allowed  to  stand  a  short  time ;  the  sublimate  solution 
is  then  replaced  by  distilled  water,  and  a  few  drops  of  triacid  solu- 
tion added.  If  the  fragments  are  coloured  green,  they  are  com- 
posed mostly  of  mucus,  and  if  red,  there  is  an  excess  of  albumin 
(Ad.  Schmidt*',  Pariser"^,  J.  Kaufmann^).  The  diagnostic  impor- 
tance of  mucus  has  already  been  dwelt  upon. 

(5)  Determination  of  Albumin 

In  testing  for  albumin  in  the  faeces,  the  latter  are  to  be  extracted 
with  a  large  amount  of  water  to  which  a  trace  of  acetic  acid  has 


EXAMINATION   OP   THE   F^CES  101 

iDeen  added,  and  the  watery  extract  filtered  a  number  of  times. 
The  filtrate  should  then  be  tested  with  the  same  reagents  as  used 
in  testing  the  urine  for  albumin ;  of  these,  acetic  acid  and  ferro- 
<jyanid  of  jDotash  are  particularly  to  be  recommended.  For  the 
■quantitative  determination  of  the  albumin,  Magnus  Blauberg ^ 
recommends  the  following  procedure :  3  to  5  grams  of  dried  faeces 
are  repeatedly  (three  or  four  times)  digested  in  ten  times  their 
volume  of  thymol  water  '^'  (each  time  for  three  or  four  hours),  and 
the  clear  supernatant  fluid  filtered  each  time  through  the  same 
filter.  To  these  combined  filtrates  are  added  one  half  their  volume 
•of  a  saturated  solution  of  sodium  chlorid  and  an  excess  of  Dragen- 
dorf's  tannin  mixture  (tannin,  20  grams ;  glacial  acetic  acid,  37.5 
grams).  After  a  while  the  filtrate  that  forms  is  brought  upon  a 
previously  washed  filter,  then  dried,  and  the  amount  of  nitrogen 
determined  by  the  well-known  Kjeldahl  method.  In  typhoid  diar- 
rhceic  evacuations  and  in  two  cases  of  acholic  stools  von  Jaksch^" 
found  demonstrable  quantities  of  albumin. 

(c)  Deter7ni)iatio)i  of  Alhu7noses  and  Pejptones 

Yon  Jaksch  ^^  employs  the  following  method :  The  faeces  are 
mixed  with  water  until  they  have  acquired  a  thin,  pasty  consis- 
tency ;  the  mixture  is  then  boiled,  filtered  while  still  hot,  and  the 
clear  filtrate  tested  for  albumin  with  acetic  acid  and  ferrocyanid 
of  potash.  Usually  a  slight  cloudiness  follows  the  addition  of 
the  acetic  acid  (mucin),  and  does  not  increase  upon  addition  of 
the  potassium  ferrocyanid.  If  such  be  the  case,  the  mucin  must 
be  precipitated  by  a  solution  of  acetate  of  lead  and  the  filtrate 
further  treated  with  phospho-tungstic  acid.  The  fluid  which  finally 
remains  should  be  tested  for  the  biuret  reaction  (caustic  soda  and 
copper  sulphate).  If,  after  the  boiling,  albumin  is  still  present,  it 
must  be  removed  by  combining  it  with  acetic  oxid  of  iron,  and  we 
then  proceed  in  the  above-described  manner.  Magnus  Blauberg  ^ 
simply  precipitates  the  combined  watery  extracts  of  the  fseces  with 
phospho-tungstic  acid,  collects  the  precipitates  which  he  dilutes 
with  water,  and  then  carefully  floats  caustic  soda  and  very  weak 
solution  of  copper  sulphate  upon  it  (biuret  test).  To  separate  albu- 
moses  from  peptones,  the  former  should  be  removed  by  "  salting  " 
them  out  with  ammonium  sulphate. 

*  Made  by  shaking  distilled  water  with  a  saturated  alcoholic  solution  of  thymol 
ior  a  long  time,  and  then  filtering. 


^02  DISEASES   OF   THE  INTESTINES 

In  normal  stools  von  Jakseh  never  found  peptones.  In  patho- 
logical stools  he  found  them  under  most  varying  conditions — fre- 
quently in  typhoid  fever,  and  wherever  much  pus  was  produced 
(dysentery,  tubercular  ulcers,  and  peritonitis,  with  rupture  into  the 
intestines).  In  affections  of  the  liver  the  relations  were  extremely 
varied.  In  the  stools  of  nurselings  Blauberg  almost  constantly- 
found  protein  substances. 

3.  Deteemixation  of  Caebohydeates  in  the  F^ces 

Hoppe- Seyl er  ^^  recommends  the  following  procedure  for  the 
determination  of  carbohydrates :  The  fasces  are  distilled,  the  residu- 
um extracted  with  alcohol  and  ether,  the  extract  boiled  with  water, 
then  filtered,  the  filtrate  partially  evaj)orated,  and  then  tested  for 
reducing  substances  by  boiling  with  dilute  sulphuric  acid,  supersat- 
urating with  caustic  soda,  and  then  adding  sulphate  of  copper  solu- 
tion. If  we  wish  to  test  for  sugar,  the  faeces  should  be  extracted 
with  water,  the  albuminoid  bodies  in  the  extract  precipitated  with 
acetate  of  lead,  the  solution  freed  from  lead  by  means  of  a  current 
of  CO2,  then  filtered,  and  the  filtrate  tested  for  sugar  by  Trom- 
mer's  or  Xylander's  test,  etc.  The  quantitative  determination  of 
sugar  is  made  with  dried  faeces,  after  the  manner  of  AUihn  and 
Liebmann. 

It  has  been  already  stated  (page  38)  that  the  carbohydrates 
are  more  completely  digested  and  utilized  than  any  other  variety 
of  nutritive  substances.  This  accounts  for  their  being  so  constantly 
absent  (at  least  in  large  quantities)  from  the  faeces.  In  numerous 
examinations  of  watery  extracts  of  the  f feces,  I  have  only  twice  ob- 
tained a  distinct  Trommer  reaction ;  with  Lugol's  solution  I  have 
never  obtained  a  reaction. 

4.    DETERMINATIOiSr    OF    FaTS    12^    THE    FjECES 

For  the  determination  of  fat  it  will,  as  a  rule,  be  sufficient  to 
shake  the  faeces  with  large  amounts  of  ether  until  nothing  more  can 
be  extracted,  and  then  to  evaporate  the  ether  over  a  water  bath. 
The  ether  takes  up  only  the  neutral  fats  and  the  fatty  acids,  but  not 
the  soaps.  The  latter  are  demonstrated  by  splitting  up- with  acids 
and  then  extracting  -with  ether.  For  the  quantitative  determina- 
tion of  the  total  amount  of  fat  in  the  stools  as  should  be  made,  and 
as  are  indispensable  in  careful  examinations  of  the  so-called  "  fatty 
stools,"  we  must  first  estimate  the  amount  of  the  neutral  fats  and  the 
fatty  acids,  then  the  fatty  acids  alone,  and  from  the  difference  we 


EXAMINATION   OF   THE   F^CES  103 

learn  the  amount  of  neutral  fats.  Finally,  through  the  agency  of 
acids,  the  fatty  soaps  in  the  remainder  of  the  first  portion  are  split 
up  into  fatty  acids,  and  as  such  are  directly  estimated.  It  would 
lead  too  far  to  enter  into  a  detailed  description  of  the  methods  in- 
volved in  these  examinations.  To  those  who  wish  to  better  acquaint 
themselves  with  them  we  recommend  Fr.  Miiller's  Studien  über 
Icterus,  Zeitschrift  für  klinische  Medicin,  Bd.  xi,  S.  45-113,  and 
von  ISToorden's  Beiträge  zur  Lehre  vom  Stoffwechsel,  Heft  1,  S. 
109  u.  f.,  Bejiin,  1892.' 

In  addition  to  the  fixed  fatty  acids,  volatile  ones — succinic, 
butyric,  propionic,  acetic — also  occur.  They  are  isolated,  and  deter- 
mined by  fractional  distillation.  For  details  the  reader  is  referred 
to  the  works  of  Iloppe-Seyler — Thierfelder,  Hammarsten  (Hand- 
buch der  Physiologischen  Chemie),  and  von  Jaksch  (Klinische 
Diagnostik,  p.  280).  I^o  diagnostic  significance  attaches  itself  to 
the  determination  of  the  volatile  fatty  acids. 

N^ormally,  fat,  especially  when  taken  in  large  quantities,  may 
appear  with  the  fgeces.  It  is  met  with  partly  as  free  fat,  in  the 
form  of  fatty  acids,  and  partly  as  soaps  of  calcium  and  magnesium. 
A  good  example  of  the  limitation  of  fat  assimilation  is  found  in  the 
taking  of  large  quantities  of  olive  oil,  such  as  are  at  present  em- 
ployed in  cholelithiasis.  In  these  cases  we  may  frequently  find  in 
the  faeces  fat  in  lumps  varying  from  the  size  of  peas  to  hazel  nuts ; 
but  when  taken  in  a  form  difficult  of  solution  (pork,  mutton,  tal- 
low, etc.),  it  will  appear  in  the  dejections  even  though  the  amount 
partaken  of  be  small.  We  speak  of  fatty  stools  only  when  the 
faeces  are  so  loaded  with  fat  that  this  is  even  macroscopically  visible. 
This  variety  of  stools  has  a  light  silver-grayish  appearance,  and  if 
allowed  to  stand  in  the  cold,  especially  after  being  previously  stirred, 
two  layers — a  lower  waxy  yellow  and  a  fascal  one — will  form.  In 
other  and  less  marked  cases  we  will  still  be  able  to  recognise  fatty 
particles  or  yellowish  translucent  fatty  plaques,  which  may  be 
isolated  for  further  examination, 

A  priori^  it  is  evident  that  fatty  stools  may  result  from  two 
causes :  either  an  incomplete  absorption  of  fat  well  split  up  and 
saponified,  or  an  insufficient  splitting  up,  whereby  its  absorption 
into  the  lymph  and  chyle  channels  is  rendered  difficult.  Finally, 
both  causes  may  act  simultaneously.  There  can  be  no  doubt  what- 
ever as  to  the  occurrence  of  the  first  possibility.  Biedert  ^^  and 
Demme^*  have  shown  this  in  catarrh  of  the  small  intestines  in 
children,  and  Fr.  Müller  ^^  in  adults  with  caseation  of  the  mesen- 


104  DISEASES   OF  THE  INTESTINES 

terial  glands.  According  to  ]Srothnagel,*  fatty  stools  occur  also  in 
atro]3liy,  amyloid  disease,  and  tuberculosis  of  the  intestines. 

It  is  more  difficult  to  explain  the  second  cause  of  fatty  stools — 
i.  e.,  anomalies  in  the  splitting  up  of  the  fat  which  result  from 
pancreatic  disease  or  from  insufficient  excretion  of  bile.  Although 
the  investigations  of  Abelmann  ^^  and  Minkowski  have  shown  that 
in  animals  after  extirpation  of  the  pancreas  absorption  of  fat  no 
longer  occurs,  control  investigations  of  Sandmeyer^'^  and  Teich- 
mann^^  have  also  shown  that,  in  spite  of  exclusion  of  the  pan- 
creatic secretion,  absorption  of  fat  will  still  take  place.  In  two 
cases  of  complete  intestinal  obstruction,  and  in  one  case  of  cystic 
degeneration  of  the  pancreas  where  large  amounts  of  fat  had  been 
given,  Fr.  Müller  ^^  could  find  no  increase  of  fat  in  the  stools. 

Absence  of  pancreatic  juice,  therefore,  does  not  prevent  the 
digestion  of  fat.  On  the  other  hand,  the  careful  and  thorough 
examinations  of  Fr.  Müller  have  shown  that  in  these  cases  an 
insufficient  splitting  up  of  fat  occurs.  Whereas  with  a  normal  secre- 
tion of  pancreatic  juice  or  in  icterus  the  greater  portion  (84  per 
cent)  of  fat  in  the  fseces  was  split  up,  only  40  per  cent  (in  round 
numbers)  was  split  up  in  the  absence  of  the  pancreatic  juice. 
Should  this  fact  be  confirmed,  it  would  constitute  an  important  sign 
for  diagnosing  disturbances  of  the  pancreatic  secretion  or  occlu- 
sions of  the  pancreatic  duct.  This  would  be  all  the  more  important, 
since  the  other  symptoms  of  these  conditions — mellituria  or  mal- 
tosuria,  multiple  muscle  fibres  in  the  stool,  and  ptyahsm — occur 
very  rarely,  and  are  only  conclusive  when  all  three  are  present. 
Conversely,  since  thorough  sphtting  up  of  fat  may  result  from 
bacterial  action,  it  does  not  at  all  speak  against  occlusion  of  the 
pancreatic  duct.  Yery  much  interest  also  attaches  itself  to  those 
acholic  stools  wdthout  icterus,  which  Bamberger  ^^  and  Gerhardt  ^*^ 
described,  and  which  have  been  particularly  studied  by  jSTothnagel  ^^, 
von  Jaksch,f  Berggrün,  and  Katz^  and  Pel.^^  I  have  observed 
five  cases  of  this  kind.  These  acholic  stools  ^vithout  icterus  are 
characterized  by  containing  a  large  percentage  of  fat  or  of  fatty 
acids.  Their  reaction,  therefore,  is  strongly  acid.  Urobilin  has 
been  repeatedly  found  in  these  colourless  stools  (in  one  of  my  own 
cases  also).  In  the  majority  of  cases  the  acholia  was  only  tempo- 
rary. In  one  case  under  my  observation  the  acholia  continued  for 
fourteen  days ;  unfortunately,  further  observation  of  the  case  was 

*  Nothnagel,  loc.  cit.,  p.  30.  f  Von  Jaksch,  Ice.  cit.,  p.  292. 


EXAMINATION  OF   THE   F^CES  105 

impossible.  The  large  amount  of  fat  present  is  very  probably  due 
to  insufficient  absorption.  It  is  unnecessary  to  repeat  that  the  rice- 
water  stools  of  cholera  nostras  and  asiatica  are  also  acholic ;  the 
cause  is  very  probably  an  entire  absence  of  intestinal  secretion. 

The  class  of  acholic  stools  under  discussion  has  been  observed 
under  the  most  varied  conditions  in  severe  as  well  as  in  light  cases. 
Thus  Nothnagel  observed  acholia  in  leukaemia,  in  cancer  of  the 
stomach  and  intestines,  in  simple  intestinal  catarrh  of  children  and 
adults,  and  most  frequently  of  all  in  advanced  cases  of  pulmonary 
tuberculosis.  Yon  Jaksch  found  acholic  stools  in  intestinal  tuber- 
culosis, chronic  nephritis,  anaemia,  and  scarlet  fever.  Berggriiu 
and  Katz  observed  and  ascribed  great  importance  to  them  in 
tubercular  peritonitis  in  children.  I  myself  have  found  acholic 
stools  in  cholelithiasis,  where  the  icterus  appeared  a  few  days  later. 
I  have  also  seen  it  in  a  very  feeble  patient  who  suffered  from 
stricture  of  the  esophagus,  and  after  the  use  of  Carlsbad  water  and 
salts  in  a  young  lady  suffering  from  chronic  catarrh  of  the  large  (and 
small  ?)  intestines  ;  furthermore,  in  a  patient  with  cancer  of  the  pan- 
creas, and  finally  in  a  severe  case  of  chronic  constipation,  where,  on 
account  of  other  clinical  manifestations,  the  probable  diagnosis  of 
cancer  of  the  large  intestines  had  been  made. 

At  present  our  ideas  as  to  the  causes  of  this  form  of  acholia  have 
a  purely  theoretical  basis.  ^Nothnagel  believes  it  is  occasioned  by 
a  temporary  cessation  of  biliary  secretion.  Yon  Jaksch  thinks  the 
lack  of  colour  is  due  to  the  non-formation  of  urobilin  from  bile  pig- 
ments, or  else  that  colourless  products  of  decomposition  of  bilirubin, 
"  leukourobilin  "  (von  l^encki),  are  formed  from  the  bile  pigments. 
The  absence  of  colour  is  very  probably  due  to  a  large  percentage  of 
fat.  We  can  readily  imagine  that,  owing  to  certain  influences  (at 
present  unknown),  the  fat,  or  rather  the  fatty  soaps,  are  only  par- 
tially or  not  at  all  absorbed  from  the  small  intestines.  On  the  other 
hand,  it  can  not  be  denied  that  the  abnormal  excretion  of  fat  from 
the  intestines  may  be  caused  by  temporary  or  permanent  disturb- 
ances of  pancreatic  or  biliary  secretions.  Owing  to  the  numerous 
possible  causes  of  this  form  of  acholia  we  can  not  at  present  assign 
any  great  diagnostic  value  to  it. 

5.  Determination  of  Blood  and  BLOOD-coLOURiNa  Matter  in 

THE    FiECES 

With  fresh  blood,  such  as  comes  from  the  lower  portion  of  the 
intestines,  the  macroscopical  appearance  of  the  fseces  is  so  char- 


IQQ  DISEASES   OF   THE  INTESTINES 

acteristic  that  a  microscopical  control  examination  will  seldom  or 
never  be  required.  Well  preserved  red  and  white  blood-corpuscles 
may  be  demonstrated.  Where  the  coloring  matter  of  the  blood  has 
undergone  changes  the  condition  is  quite  different.  The  presence 
of  blood-colouring  matter  may  be  demonstrated  by  microscopical, 
chemical,  and  spectroscopic  analyses,  which  will  now  be  collectively 
considered. 

{a)  Blood,  when  present  in  the  fseces,  can  seldom  be  demon- 
strated by  microscopical  examination.  Even  where  the  stools  were 
still  intensely  red  coloured,  Nothnagel  never  could  find  erythrocytes 
in  the  fresh  haemorrhages  of  typhoid  fever.  In  these  cases,  how- 
ever, we  can  observe  clumps  of  pigment  which,  according  to  von 
Jaksch,*  are  composed  of  hsematoidin. 

{}))  The  Micro-clieinical  Demonstration  {Hcemin  Test). — A  small 
particle  of  fseces  that  appears  to  contain  blood-colouring  matter  is 
dried,  then  pulverized,  and  together  with  a  minute  particle  of  com- 
mon salt  and  one  drop  of  glacial  acetic  acid  brought  upon  a  glass 
slide,  and  the  whole  mixed  carefully  for  a  few  moments.  A  cover 
glass  is  then  placed  over  the  mixture  and  glacial  acetic  acid  allowed 
to  flow  under  the  cover  glass  until  the  latter  uniformly  touches  the 
slide.  Thereupon  the  slide  is  held  over  a  Yery  small  flame,  care 
being  taken  that  the  glacial  acetic  acid  does  not  reach  the  boiling 
point ;  the  heating  may  be  repeated  with  the  addition  of  fresh  gla- 
cial acetic  acid.  When  the  specimen  has  cooled  it  is  examined  with 
the  high  power  for  hsematin  crystals.f 

{c)  Chemical  Demonstration  (  Weber'' s  Test  ^^). — The  faeces  are 
extracted  with  glacial  acetic  acid  and  ether,  and  to  a  few  cubic  cen- 
timetres of  this  extract  10  drops  of  the  tincture  of  guaiac  and  30 
drops  of  oil  of  turpentine  are  added.  In  the  presence  of  hsematin 
we  can  observe  a  pretty  blue  or  violet  colour,  which,  after  the 
addition  of  water,  can  be  extracted  with  chloroform. 

{cl)  Spectroscopic  Demonstration. — A  portion  of  the  most 
darkly  coloured  part  of  the  faeces  is  stirred  with  a  little  water, 
and,  after  the  addition  of  a  few  drops  of  concentrated  acetic  acid, 
shaken  with  one  fifth  its  volume  of  ether ;  after  a  few  moments  the 
ether  separates,  and,  if  the  fseces  contain  blood,  is  coloured  "a  brown- 
ish red  (due  to  the  haematin).  The  ethereal  haematin  solution  shows 
four  spectroscopic  absorption  bands :  one  in  the  red,  a  second  in 


*  Von  Jaksch,  loc.  eit.,  p.  232. 
•|-  For  unknown  reasons  the  hajinin  test  with  faeces  does  not  always  succeed. 


EXAMINATION   OF   THE   FiECES  lOY 

the  yellow,  a  third  between  the  yellow  and  the  green,  and  a  fourth 
between  the  green  and  the  blae.  That  in  the  red  is  by  far  the 
darkest  and  most  clearly  defined. 

In  most  cases  the  demonstration  of  blood  in  the  faeces  is  easj', 
but  the  determination  of  its  origin  is  more  difiicult.  In  the  first 
place,  we  must  remember  that  blood  may  be  pliysiologically  intro- 
duced into  the  fteces  through  raw  meat  and  some  varieties  of  sausages. 
If  these  can  be  excluded  a  large  amount  of  blood  in  the  faeces  is 
always  a  pathological  condition.  The  causes  are  so  numerous  and 
varied  that  only  through  general  and  local  examinations  can  the 
source  be  determined.  The  diseases  of  the  intestines  which  fre- 
quently or  occasionally  cause  haemorrhages  include  ulcers,  neo- 
plasms, haemorrhoids,  amyloid  disease,  intussusception,  stenosis, 
ileus,  anchylostomum,  bothriocephalus,  trichocephalus  disjDar,  etc. 

6.  Demonsteation  of  Biliary  Mattee  in  the  F^ces  (Bile 
Pigments,  Biliaet  Acids) 

As  previously  mentioned,  the  brown  colour  of  normal  stools  is 
due  to  colouring  substances  formed  through  reduction  of  the  bili- 
rubin or  of  the  biliverdin  of  the  bile.  In  adults,  unaltered  bile 
pigment  (bilirubin,  biliverdin)  appears  under  pathological  conditions 
only.  Hence  the  demonstration  of  normal  as  well  as  of  abnormal 
faecal  colouring  matter  may  have  some  diagnostic  value. 

{a)  Demonstration  of  Bile  Pigments  in  Toto  {Hujpjperfs  Test) 

Thio  fluid  feces  (or  artificiallj' thinned  fseees)  are  placed  in  a  flask,  an  equal 
volume  of  milk  of  lime  is  added,  and  after  repeated  shaking  the  mixture  is 
poured  upon  a  small  filter;  the  precipitate  which  remains  upon  the  filter  con- 
sists of  hydrobilirubin  lime.  This  should  be  washed,  and,  w^hile  still  moist, 
placed  into  a  boiling  flask  with  a  very  long  neck,  together  with  20  cubic 
centimetres  of  alcohol  to  which  sulphuric  acid  has  been  previously  added  to 
distinct  acid  reaction.  The  mixture  is  heated  to  boiling;  in  the  presence  of 
biliary  colouring  matter  the  fluid  will  acquire  an  emerald  green  or  a  bluish 
green  colour.  Positive  reaction  with  Huppert's  test  simply  indicates  the  pres- 
ence of  bile  pigment  in  the  faeces,  but  tells  nothing  of  its  nature. 

(jb)   Test  for  Tfrobilin 

1.  Mehu's  test.  The  f«ces  are  extracted  with  water  and  sulphuric  acid 
in  proportion  to  2  grams  to  the  litre  and  ammonium  sulphate  in  substance 
are  added  to  the  watery  extract.  The  resulting  precipitate  is  separated  by 
filtration,  washed  with  a  warm  saturated  solution  of  ammonium  sulphate, 
dried  over  a  water  bath,  and  then  extracted  with  hot  ammoniated  alcohol. 
Spectroscopic  examination  of  this  extract  shows  an  absorption  band  between  B 


108  DISEASES  OF  THE  INTESTINES 

and  F.  The  precipitate  may  be  otherwise  treated ;  it  may  be  dissolved  with 
ammoniated  water  and  a  10-per-cent  solution  of  chlorid  of  zinc  added.  In  the 
presence  of  urobilin  the  fluid  will  show  a  very  pretty  fluorescence. 

3.  A.  Schmidt's  test.^'  With  a  glass  rod  a  fragment  of  f«ces  about  the 
size  of  a  bean  is  rubbed  up  in  a  beaker  or  porcelain  dish  with  a  concentrated 
watery  sublimate  solution.  If  urobilin  be  present  the  mixture  immediately, 
or  after  a  short  time,  acquires  a  rose  colour ;  or  if  biliverdin  be  present,  a  green 
colour.  According  to  the  experiments  of  Dr.  Hari  in  my  laboratory,  the 
reaction  can  be  more  quickly  obtained  by  shaking  the  faeces  with  concentrated 
sublimate  solution,  filtering,  and  then  adding  chloroform  to  the  filtrate.  In 
the  presence  of  urobilin  a  very  pretty  rose  colour  appears  at  the  point  of  contact 
of  the  two  fluids. 

3.  Fleischer's  method.'"'  If  a  small  quantity  of  faeces  be  placed  in  a 
small  flask  or  a  test  tube  and  alcohol  (to  which  hydrochloric,  sulphuric,  or 
acetic  acid  has  previously  been  added)  be  poured  over  it  and  the  whole  allowed 
to  stand  a  short  time,  it  will  be  coloured  yellowish  or  brownish,  according  to 
the  proportion  of  urobilin  contained.  If  the  alcohol  be  then  poured  off  and  a 
few  drops  of  caustic  soda  or  ammonia  solution  added,  and  then  chlorid  of  zinc 
solution,  a  green  fluorescence  with  direct  light  and  a  rose-coloured  or  yellowish 
with  transmitted  light  will  be  obtained.  The  degree  of  colour  reaction  is 
proportionate  to  the  amount  of  urobilin  present  in  the  stools.  If  ammonia 
solution  be  added  to  a  watery  extract  of  the  faeces,  and,  after  filtration,  chlorid 
of  zinc  solution,  we  will  obtain  a  beautiful  rose  red  or  a  dark  red  precipitate 
in  the  presence  of  urobilin ;  in  the  absence  of  urobilin,  however,  this  precipi- 
tate will  remain  uncoloured.  If  this  precipitate  is  brought  upon  a  filter  and 
washed  with  ammoniated  alcohol,  we  will  obtain  a  more  or  less  marked  green- 
ish fluorescence. 

(c)  Determination  of  Unreduced  Bile  Pigments  {Bilirubin, 
Biliverdin),  Gmelhi's  Test 

If  nitroso-nitric  acid  be  added  to  the  faeces,  the  characteristic 
colours — red,  violet,  and  green — will  appear  (in  most  cases  only  a 
green  colour  is  seen).  In  like  manner,  after  filtration  of  the  faeces, 
we  can  obtain  this  test  with  the  dried  filter  paper.  In  order  to 
demonstrate  bile  pigment  micro-chemically,  a  drop  of  the  same  acid 
is  added  to  a  small  particle  of  faeces  placed  upon  a  glass  slide.  The 
reaction  can  be  obtained  either  with  the  entire  faeces  or  else  with 
some  of  the  ingredients — viz.,  mucus,  epithelium,  muscle  fibres,  etc. 

{d)  Determination  of  Bile  Acids 

A  small  quantity  of  the  faeces  is  extracted  with  alcohol,  the 
latter  evaporated,  and  the  residue  dissolved  in  a  very  weak  watery 
solution  of  soda.  Upon  addition  of  cane  sugar  and  a  few  drops 
of  sulphuric  acid  the  characteristic  red  and  purple  colours  of  the 
bile  acids  appear  (Pettenkojffer's  test).     Since  the  greater  portion  of 


EXAMINATION  OF   THE   F^CES  109 

bile  acids  normally  disappear  by  absorption,  their  presence  in  the 
dejections  is  always  pathological. 

The  diagnostic  significance  of  the  tests  for  biliary  pigment  in  the 
fseces  hes  mainly  in  the  fact  that  their  presence  proves  a  completely 
unobstructed  flow  of  bile  into  the  intestines,  while  their  absence 
speaks  for  an  obstruction  to  the  flow  of  bile.  According  to  Noth- 
nagel,^ normal  biliary  pigment  can  be  demonstrated  only  in  thin, 
pasty,  and  fluid  evacuations  by  Gmelin's  test.  If  in  such  evacua- 
tions distinct  reaction  for  bihary  pigments  is  obtained,  and  the 
biliary  pigment  clings  to  the  mucus  or  to  the  cylindrical  epithelium, 
it  points  to  catarrh  of  the  small  and  of  the  large  intestines.  With  a 
well-marked  reaction  we  are  justified  in  assuming  that  catarrh  of 
the  upper  part  of  the  small  intestine  is  also  present. 

7.  Absence  of  Bile  Pigment  (Acholia)  and  Colourless  Stools 

Whenever  there  is  an  obstruction  to  the  flow  of  bile,  colourless, 
clay -coloured  stools  result;  also  absolutely  colourless  stools  may 
occur  when  there  is  no  obstruction  in  the  biliary  passages.  In 
obstruction  to  the  flow  of  bile  lack  of  colour  is,  on  the  one  hand, 
due  to  an  absence  of  bile  pigments,  and  on  the  other  to  the  pres- 
ence of  abnormal  amounts  of  fat  and  fatty  acid  in  the  stools. 

Bunge  "  has  pointed  out  that  the  clay  colour  is  due  not  to  the  absence  of 
bile  pigment  but  to  the  presence  of  large  amounts  of  fat.  If  we  extracted  such 
acholic  stools  repeatedly  with  ether,  they  would  assume  a  brownish  colour, 
which,  according  to  Bunge,  results  from  the  presence  of  hsematin  and  sulphate 
of  iron.  Guided  by  this,  Fleischer'''*  examined  for  and  actually  found  ha^ma- 
tin  in  the  three  acholic  stools;  in  a  fourth  he  did  not  succeed.  In  all  four 
stools  urobilin  was  entirely  absent.  From  these  investigations  Fleischer 
hopes  for  a  better  understanding  of  the  causes  and  the  nature  of  acholia  in 
the  faeces. 

Acholic  stools  occurring  simultaneously  with  icterus  point  to  an 
affection  of  the  liver,  the  nature  of  which  can  only  be  determined 
by  a  closer  examination. 

8.    Determination  of  Aromatic  Substances  in  the  F^ces 
(Phenol,  Indol,  and  Skatol) 

These  aromatic  bodies  occur  normally  as  well  as  pathologically. 

(a)  Phenol. — To  demonstrate  the  presence  of  phenol  a  portion 
of  fseces  must  be  distilled,  and  the  distillate  made  alkaline  with 
caustic  potash  and  again  distilled.  The  phenol  then  remains,  and 
is  purified  by  distillation  with  sulphuric  acid.     By  the  addition  of 


110  DISEASES  OP   THE   INTESTINES 

bromin  water  it  can  be  demonstrated  in  the  distillate  as  tribromo- 
phenol.  Upon  beating  the  distillate  with  Millon's  reagent  a  red 
colour  is  obtained.  A  violet  colour  is  obtained  bj  the  addition  of 
chlorid  of  iron. 

{h)  Indol  and  SJcatol  (Brieger). — To  separate  these  bodies  from 
phenol,  the  distillate  of  the  faeces,  after  being  made  alkaline,  is  again 
distilled.  Indol  and  skatol  then  pass  over  Avith  the  vapour  of  water. 
Indol  forms  colourless  scales,  and  is  soluble  in  hot  water  and  in 
alcohol.  Skatol  also  forms  colourless  scales,  but  is  soluble  with 
much  more  difficulty  in  water,  and  has  a  disagreeable  penetrating 
odour.  Unlike  indol,  it  is  not  decomposed  by  caustics.  With  nitroso- 
nitric  acid  indol  gives  a  distinct  red  colour ;  when  more  concentrated 
a  red  precipitate  may  result.  Pine  shavings  moistened  with  muri- 
atic acid  are  coloured  red  in  a  short  time  by  an  alcoholic  solution 
of  indol.  Skatol  gives  neither  the  first  nor  the  second  test.  At 
present  these  substances  have  no  diagnostic  significance,  but  a 
suitable  method  for  their  quantitative  determination  would  very 
probably  enable  us  to  recognise  different  degrees  of  putrefaction 
within  the  intestines. 

9.    Detkeminatios'  of  Fekments  in  the  F^ces 

For  the  purpose  of  demonstration,  the  ferments  may  be  extracted 
with  glycerin,  and  the  glycerin  extract  used ;  or,  what  is  simpler, 
the  fgeces  may  be  stirred  with  thymol  or  chloroform  water,  then  fil- 
tered, and  the  tests  made  with  the  filtrate.  For  f^ces,  Leo^^  also 
recommends  the  use  of  blood  fibrin,  which  has  the  property  of 
absorbing  ferments  (discovered  by  Wittich).  For  this  purpose  faeces 
are  mixed  with  chloroform  water  until  they  form  a  thin,  pasty  mass. 
In  this  mixture  we  suspend  2  to  5  grams  of  finely  divided,  pre- 
viously boiled  blood  fibrin,  which  is  inclosed  in  a  gauze  bag  tied 
with  a  thread.  After  twenty -four  hours  the  gauze  bag  is  taken  out 
of  the  faeces,  the  fibrin  washed  a  number  of  times  with  water,  and 
then  tested  for  the  various  ferments.  To  test  for  diastase,  a  small 
piece  of  fibrin  is  placed  with  some  thin  starch  paste  in  an  incubator, 
and  after  a  while  is  tested  with  diluted  Lugol's  solution  for  the  pres- 
ence of  sugar  or  the  disappearance  of  starch. 

To  test  for  trypsin,  a  few  pieces  of  fibrin  in  a  1-per-cent  solution 
of  soda  are  placed  for  a  while  in  the  incubator,  and  then  tested  for 
albumoses  with  caustic  potash  and  very  dilute  sulphate  of  cop- 
per solution.  If  albumoses  are  present  a  pretty  rose-red  [or  onion- 
red]  colour  is  produced  (biuret  reaction).     Yon  Jaksch^^  and  Leo^^ 


EXAMINATION   OP   THE   FiECES  HI 

have  demonstrated  the  presence  of  ferments  in  the  dejections ; 
diastase  and  invertin  were  found  in  children  by  von  Jaksch,  in  adults 
by  Leo.  In  normal  and  in  many  pathological  conditions  Leo  was 
unable  to  find  tryptic  ferments,  but  he  did,  however,  find  them  in 
many  cases  of  diarrhoea.  In  a  case  of  jejunal  diarrhcea  I  found 
both  amylolytic  and  tryptic  ferments. 

10.    Deteemination  of  Biliaky  Geavel  and  Gall  Stones  in 

THE    F^CES 

As  is  well  known,  biliary  gravel  and  gall  stones  very  often  appear 
in  the  stools  after  attacks  of  cholelithiasis.  They  are  very  readily 
recognised  in  some  cases,  particularly  where  the  stones  are  of  large 
size,  or  are  j)assed  in  large  numbers.  On  the  other  hand,  the  macro- 
scopical  recognition  of  biliary  gravel  is  more  difiicult.  Cholesterin 
is  the  principal  ingredient  of  these  concrements.  In  addition,  they 
contain  bile  pigment  combined  with  calcium  (bilirubin-calcium),  and 
bile  acids  combined  with  calcium,  calcium  soaps,  and  the  carbonate 
of  calcium.  Appearance,  colour,  consistency,  and  size  of  the  stones 
vary  according  to  the  proportion  of  the  different  ingredients.  We 
differentiate  especially  between  Cholesterin  stones  which  are  hard 
and  concentrically  formed,  and  dark  pigment  stones  which  are  not 
concentric,  and  are  soft,  small,  and  composed  principally  of  bilirubin 
calcium. 

Chemical  Examination.- — This  includes  principally  the  demon- 
stration of  Cholesterin  and  biliary  pigments.  The  concrements 
are  pulverized  in  a  mortar,  and  in  order  to  remove  all  biliary 
components  are  boiled  in  water.  After  drying,  the  residue  is 
extracted  with  a  mixture  of  equal  parts  of  alcohol  and  ether.  This 
extract  is  then  poured  off,  evaporated  over  a  water  bath,  and  under 
the  microscope  shows  Cholesterin  in  large  rhombic  plates  with  step- 
like notches.  Chemically,  Cholesterin  can  be  demonstrated  by  dis- 
solving a  portion  of  the  residue  in  chloroform  and  adding  an  equal 
amount  of  concentrated  sulphuric  acid.  The  chloroform  solution 
then  shows  the  following  play  of  colours :  blood-red,  purple-red, 
and  after  longer  exposure  to  the  air,  blue,  green,  and  finally  yellow. 
The  micro-chemical  demonstration  of  Cholesterin  is  still  easier.  If 
to  the  crystalline  mass  on  a  glass  slide  concentrated  sulphuric  acid 
be  added,  the  edges  of  the  crystals  will  assume  a  carmin  colour, 
which  upon  the  addition  of  Lugol's  solution  changes  to  violet. 

To  demonstrate  gall-stone  fragments  we  add  dilute  sulphuric 
acid  to  the  residue  left  after  boiling  with  water  [vide  above).     The 


11^  DISBASES  OF   THE   INTESTINES 

formation  of  gas  shows  tlie  presence  of  a  carbonated  salt.  The 
mixture  is  heated,  and  after  cooling  is  extracted  with  chloroform. 
With  this  chloroform  extract  Gmelin's  test  (see  page  108)  is  to  be 
made. 

For  further  tests  for  the  various  ingredients  of  bile  concrements, 
the  reader  is  referred  to  text-books  on  physiological  chemistry. 

11.    Panceeatic  Stones 

Pancreatic  calculi  are  very  rarely  passed  in  the  stools.  These 
stones  have  a  rough  surface,  are  friable,  and  can  be  broken  off  in 
facets.  They  are  readily  soluble  in  chloroform,  and,  according  to 
Minich,^"  when  heated  evolve  an  aromatic  odour.  In  one  of  Leicht- 
enstern's^^  cases  chemical  examination  showed  only  carbonate  and 
phosphate  of  calcium,  but  no  bile  pigment  or  Cholesterin.  The 
finding  of  pancreatic  stones  is  of  considerable  diagnostic  interest,, 
for  it  proves  conclusively  the  existence  of  a  calculus.  Unfortun- 
ately, owing  to  their  great  friability  we  rarely  find  these  stones. 
We  would,  however,  recommend  that  the  dejections  be  examined  in 
cases  of  cholelithiasis  without  icterus,  and  particularly  in  cases  of  the 
so-called  "neuralgia  of  the  hver." 

12.    FiECAL  Stones  (Copkoliths)  and  Intestinal  Stones 

(Enteroliths) 
Fsecal  stones  or  coproliths  are  formed  from  inspissated  masses 
of  faeces  and  may  acquire  a  size  and  firmness  sufficient  to  cause 
obstruction  of  the  intestine.  They  develop  in  portions  of  the 
large  intestine  in  which  the  outward  pro]3ulsion  of  the  contents  is 
attended  with  difficulty — i.  e.,  at  the  flexures  and  in  the  ampulla 
of  the  rectum.  As  is  well  known,  the  vermiform  appendix  is  a 
special  point  of  predilection  for  fgecal  stones  (see  chapter  on  Ap- 
pendicitis, in  Part  II).  Keal  enteroliths,  on  the  other  hand,  are 
much  smaller  bodies,  and  only  very  seldom  give  rise  to  intestinal 
obstruction.  According  to  Leichten  stern's  investigations,  we  may  dis- 
tinguish three  forms  of  enteroliths,  viz. :  1.  Heavy,  brown,  con- 
centric concrements  of  stony  consistency,  composed  mainly  of  phos- 
phates of  calcium  and  magnesium,  and  containing  some  foreign  body 
in  their  interior  (e.  g.,  pieces  of  bone,  hairs,  fruit  seeds,  ascarides, 
ova,  etc.).  2.  Stones, light  in  weight,  composed  of  a  fungoid  mass 
of  undigested  vegetable  matter.  They  occur  in  poor  people  who 
eat  much  oatmeal  (oat  stones).  3,  Stones  resulting  from  long-con- 
tinued use  of  certain  drugs  (calcium  carbonate,  magnesia,  sodium 


EXAMINATION   OP   THE   FiECES  113 

"bicarbonate,  salol,  alcoholic  solutions  of  shellac,  etc.).  This  variety 

may  acquire  a  considerable  size.      For  the  chemical  character  of 

these  stones  the  reader  is  referred  to  text-books  on  physiological 
and  pathological  chemistry. 

13.  Determination  of  Inoeganic  Substances  in  the  F^ces 

The  faeces  contain  inorganic  salts  in  amounts  varying  from  1  to 
8  per  cent.  These  consist  principally  of  earthy  phosphates ;  in 
addition,  there  are  also  small  amounts  of  iron,  silicic  acid,  sodium 
chlorid,  sodium  sulphate,  etc.  Of  the  soluble  inorganic  substances, 
sodium  chlorid,  at  all  events,  possesses  practical  interest.  To  dem- 
onstrate its  presence,  the  faeces  should  be  mixed  with  water  and 
a,llowed  to  stand  a  few  hours  and  then  filtered.  The  filtrate  is 
acidulated  with  nitric  acid,  and  if  a  cloudiness  results  should  be  again 
filtered.  Thereupon  a  few  drops  of  silver  nitrate  are  added  and  a 
white  precipitate  forms  (silver  chlorid).  For  the  quantitative  de- 
termination of  sodium  chlorid,  see  the  text-book  of  Hoppe-Seyler 
and  Thierfelder.^'^ 


3.    The    Microscopical    Examination 

Teehnic. — Thin,  pasty,  or  fluid  faeces  may  be  examined  with- 
out special  preparation.*  For  the  better  examination  of  the  insol- 
uble portions,  fluid  faeces  may  be  poured  into  a  conicall_y  shaped 
glass,  or,  still  better,  centrifuged  (Herz^^).  In  the  case  of  firm 
stools,  a  small  particle  is  taken  and  mixed  with  physiological  salt 
solution.  For  very  exact  examinations  it  is  best  to  take  only  par- 
ticles the  size  of  a  pin's  head.  The  ingredients  to  be  microscop- 
ically examined  for  are : 

1.  Food  remnants. 

2.  Elements  derived  from  the  intestines. 

3.  Micro-organisms. 

4.  Crystalline  bodies. 

1.  The  following  food  remnants  are  met  with  normally  or 
pathologically  : 

{a)  Muscle  Fibres. — These  occur  not  only  in  excessive  meat 
diet,  but  also  in  mixed  diet.  They  may  have  well-preserved  striae, 
or  more  frequently  they  are  seen  as  prismatic  bodies  with  indis- 
tinct or  obliterated  striae.     JSTothnagel,^^  however,  states  that  with 

*  The  addition  of  1-  or  2-per-cent  formalin  solution  effectively  deodorizes  faeces. 


114  DISBASES   OF   THE  INTESTINES 

the  very  high  power  even  in  these  cases  he  could  observe  trans- 
verse striations.  Occasionally  the  muscle  fragments  can  be  readily 
recognised  raacroscopically,  or  even  singled  out  as  brown  spots. 
Under  most  diverse  conditions  muscle  fibres  are  found  in  increased 


?  / 


f 


*w 


Fig.  13. — Diffekent  Vegetable  Substances  found  in  F^ces. 
(Original  observation.) 

numbers ;  in  diabetics,  who,  as  is  well  known,  eat  very  much  meat, 
in  persons  sufiiering  from  fever,  particularly  when  there  is  increased 
peristalsis  (e.  g.,  typhoid) — in  fact,  in  any  condition  in  which  there 
is  a  marked  increase  in  the  peristalsis  of  the  small  and  large 
intestines.  In  general  the  appearance  even  of  large  numbers  of 
muscle  fibres  in  the  fseces  has  no  diagnostic  significance.  Only 
their  constant  increase  has  any  definite  value.  In  the  following 
sentence  E'othnagel  very  carefully  formulates  this  law:  "Only 
where,  in  the  absence  of  fever  and  in  the  presence  of  definite  symp- 
toms of  catarrh  (mucus,  etc.),  we  find  an  abnormally  large  amount 
of  muscle  fibre  in  the  fgeces,  is  it  permissible  to  conclude  that 
catarrh  of  the  small  intestines  is  very  probably  also  present." 

I  fully  agree  with  this  statement,  and  would  complete  it  by 
remarking  that  the  macroscopical  rather  than  the  microscopical 
examination  is  decisive.  Should  we  constantly  observe  undigested 
masses  of  meat,  together  with  large  quantities  of  mucus  in  the 
faeces  of  patients  under  moderate  meat  diet  and  with  well-preserved 
teeth,  the  diagnosis,  catarrh  of  the  small  intestines,  is  almost  cer- 
tain. The  reverse  of  this  statement  is  not  true.  Although  it  is  true 
that  in  pancreatic  disease  large  quantities  of  muscle  fibres  fre- 
quently appear  in  the   stools,  we    may  to-day  regard   as   entirely 


EXAMINATION   OF   THE   F^CES  115 

disproved  the  opinion  defended  by  Friedreich  ^^  a  number  of 
years  ago,  viz.,  that  abundance  of  muscle  fibres  in  the  faeces  indi- 
cates pancreatic  disease. 

(h)  Starch. — formally,  and  also  in  disease,  starch  is  so  com- 
pletely digested  that  the  appearance  in  the  faeces  of  numerous 
vegetable  remnants,  and  especially  of  well-preserved,  concentrically 
arranged  starch  granules,  is  of  pathological  significance.  According 
to  my  investigations,  the  following  differences  have  been  noted  : 
Upon  the  addition  of  iodin  to  the  faeces,  in  many  cases  a  blue  col- 
our is  obtained,  while  in  others  again  a  more  violet  or  even  a  rose 
colour  appears.  Without  doubt  the  first  colour  (blue)  is  indicative 
of  a  more  serious  interference  with  starch  digestion.  Besides  iso- 
lated starch  granules  we  may  also  find  vegetable  remnants  that  con- 
tain starch,  and  which  appear  either  as  threads,  particularly  spirals, 
or  as  large,  square,  meshlike  bodies  (Fig.  13)  frequently  contain- 
ing chlorophyl,  or,  finally,  as  large  striated  globules  similar  to  those 


Fig.  14. — Fatty  Stools,  showing  a  Large  Amount  of  Fatty  Acid  Crystals. 
(Original  observation.) 

that  I  have  described  and  pictured  in  the  stomach  contents.^"^  It 
is  very  remarkable  that  starches,  unlike  muscle  fibres  and  fats,  are 
never  stained  by  bile  pigment. 

(c)  J^ats. — Fat  appears  either  in  the  form  of  drops  or  of  col- 
ourless, occasionally  yellowish,  clumps.     Fat  crystals  consist  either 


116 


DISEASES  OF  THE  INTESTINES 


of  fatty  acids  or  of  fatty  soaps.  Fatty  acids  (Fig.  14)  are  short, 
delicate,  partly  curved  needles,  whereas  the  soaps  (Fig.  15)  are 
formed  as  long  needles  arranged  in  clusters  or  fan-shaped.  When 
heated  oyer  a  flame  the  fatty  acids  dissolve,  but  the  soaps  remain 
unchanged.  Fatty  acids  are  soluble  in  ether ;  soaps  are  only  soluble 
in  ether  after  previous  sphtting  up  by  acids.  These  characteristics 
enable  us  in  every  case  to  determine  the  nature  of  fatty  crystals. 

Rieder^  has  recently  recommended  a  new  colour  reagent  for 
fats,  suitable  for  clinical  purposes.     It  is  known  as  Sudan  III,  and 


Fig.  15. — Fatty  Soaps  in  F^ces. 

Taken  from  a  case  of  chronic  catarrh  of  the  small  and  large  intestines. 

(Original  observation.) 

is  a  diazo-colouring  substance  with  the  formula  C22II10N4O.  It  is 
employed  in  concentrated  alcoholic  solution,  filtered  just  before 
using.  In  fatty  stools  the  fat  drops  are  stained  from  an  orange  to  a 
blood-red  colour,  while  fatty  acid  needles  and  calcium  and  mag- 
nesium soaps  remain  uncoloured. 

{d)  Coagulated  Alhuinen. — In  diarrhoeal  stools,  especially  after 
excessive  dieting  with  milk,  we  may,  according  to  ITothnagel,  see 
lumps  of  casein  varying  in  size  from  half  a  lentil  to  a  pea,  and  fre- 
quently stained  externally  with  bile,  while  internally  they  are  as 


EXAMINATION   OF   THE   P^CES  117 

white  as  milk.  In  like  manner,  after  eggs  have  been  partaken  of 
in  large  quantities,  small  fragments  of  them  may  be  observed  in 
the  dejections. 

2.  The  substances  derived  from  the  intestines  themselves  in- 
clude red  and  white  blood  cells  (pus  cells),  epithelium,  mucus,  and 
tumour  fragments. 

{a)  Blood  and  P%is  Cells. — Regarding  the  red  blood  cells  I 
would  refer  the  reader  to  what  has  been  already  said  on  page  106. 
Although  exceedingly  rare,  white  blood  cells  do  appear  normally  in 
the  stools  ;  they  are  more  frequently  met  vtdth  in  pathological  stools, 
and  are  most  frequent  in  catarrhs.  Their  appearance  in  great  num- 
bers indicates  ulcerative  processes  within  the  intestinal  canal.  The 
most  important  facts  concerning  this  subject  have  already  been 
considered  on  pages  64  and  95. 

(J)  EpiiJielium. — This  is  usually  of  the  cylindrical  and  but  sel- 
dom of  the  pavement  variety.  Yery  rarely  in  diseases  of  the  rec- 
tum (rectal  cancer,  proctitis)  we  find  pavement  epithelium.  It  is, 
however,  of  no  symptomatic  importance.  Cylindrical  epithelium 
is  more  important.  It  may  be  unaltered,  or  more  frequently  can 
assume  the  greatest  alterations  in  form.  The  cells  may  or  may 
not  retain  their  nucleus  (degenerated  epithelium).  Microscopically 
we  may  observe  all  possible  changes  from  the  normal  appear- 
ance of  epithelium  to  that  of  degeneration.  Minute  fat  globules 
are  also  frequently  seen  in  the  epithelial  cells.  A.  Schmidt  ^^  has 
indisputably  proved  that  mucous  shreds,  too,  may  contain  a  consider- 
able amount  of  fat.  Fig.  16  explains  all  this  much  better  than  any 
description  could.  Epithelial  cells  are  best  studied  in  fresh  mucus, 
such  as  is  obtained  in  test  lavage.  In  a  few  instances  I  have  also 
noticed  goblet  cells,  occasionally  with  intact  basement  membrane. 
Large  quantities  of  cylindrical  epithelium  with  mucus  usually  indi- 
cates a  desquamative  catarrh,  whose  location  must  be  determined  by 
other  symptoms  and  signs,  some  of  which  have  already  been  men- 
tioned. In  addition  to  these  formed  structures  in  normal  and 
pathological  fseces,  we  may  also  find  large  and  small  bodies  that  can 
be  diiferentiated  with  difiScnlty  and  that  are  extremely  resistant  to 
reagents.  This  detritus  is  derived  in  part  from  the  food  as  Avell  as 
from  the  secretions  and  excretions  of  the  intestines. 

(ö)  Miicin. — Mucin  is  mainly  characterized  by  its  striated  base- 
ment substance,  in  which  epithelial  cells  are  embedded  in  varying 
numbers.  In  some  cases  the  cells  predominate  to  such  an  extent 
that  the  striated  structure  of  the  macin  becomes  indistinct   or  is 


118 


DISEASES   OF   THE  INTESTINES 


apparently  absent.  Still,  in  some  portions  of  the  specimen  it  will 
always  be  recognisable  by  its  lay  er  like  appearance.  In  doubtful 
cases  its  presence  can  be  determined  by  the  Hoyer-Elirlich  thionin 
colour  test.  Mucus  is  here  coloured  a  reddish  violet,  and  all  other 
proteid  bodies  blue.  According  to  Sven  Akerlund,^^  eosin,  safranin, 
methylene  blue,  and  hsematoxylin  also  colour  mucus  very  satis- 
factorily, but  not  so  as  to  admit  of  any  differentiation  from  other 
proteid  bodies.  We  have  already  discussed  the  significance  of 
mucus  in  the  faeces  (page  95).     We  would,  however,  repeat  that 


Fig.  16.- 


-Normal  and  Degenebated  Epithelial  Cells  from  the  Mucous  Shreds  of  a. 
Case  of  Membranous  Enteritis.     (Original  observation.) 


pure,  macroscopically  visible  mucus,  such  as  is  obtained  in  intes- 
tinal lavage,  can  only  come  from  the  large  intestines. 

3.  Micro-organisms. — The  faeces  contain  a  greater  number  of 
micro-organisms  than  any  other  excretion  of  the  body.  They  cer- 
tainly play  a  great  physiological  and  pathological  role.  jS^otwith- 
standing  that  the  important  investigations  of  ]N"encki,-  Macfadyen, 
and  Sieber,^^  as  well  as  of  Thierfelder  and  N^uttal,^  have  shown  that 
normal  digestion  is  possible  without  the  aid  of  bacteria,  we  can  not 
deny  them  some  significance.  Their  activity  need  not  be  limited  to 
action  upon  digestive  matter,  })ut  may  also  include  reciprocal  action 
on  other  pathogenic  organisms.  As  usual  in  bacteriology,  we  here 
distinguish  moulds,  yeasts,  and  schizomycetes  (bacteria). 


EXAMINATION  OP   THE   F^CES  119 

(a)  I  have  but  once  observed  mould  fungi  in  faeces  (aspergillus 
filaments).  The  oidinm  albicans  has  occasionally  been  observed  in 
the  stools  of  children. 

(b)  SaccharoTYiyces. — Of  these  the  yeast  is  the  most  important. 
It  is  a  frequent  constituent  of  normal  and  quite  commonly  of  patho- 
logical stools.  It  appears  either  as  single  cells  or  in  pearly  chains. 
It  frequently  shows  budding.  Usually  the  cells  are  oval,  more 
rarely  they  are  round.  We  find  them  both  in  firm  and  in  diarrhoeal 
evacuations,  although  they  are  more  common  in  the  latter  variety. 
The  reaction  of  the  fseces  seems  to  have  no  influence  upon  their 
growth,  for  I  have  met  with  them  in  alkaline  as  well  as  in  acid 
stools.  With  Lugol's  solution  they  are  stained  a  yellowish  or 
mahogany  brown.  Yon  Jaksch  quite  correctly  calls  attention  to  the 
occurrence  in  the  faeces  of  bodies  very  similar  to  yeast  cells,  but  I 
have  noticed  that  they  are  for  the  most  part  smaller  than  yeast 
cells  and  have  no  double  contour  and  do  not  bud.  Furthermore, 
they  differ  from  yeast  cells  in  giving  the  same  reaction  as  starch 
with  Lugol's  solution.  They  should  very  probably  be  classed  with 
the  Clostridien  (page  121). 

(c)  Sarcina  (Groodsir)  (Fig.  17). — Strange  to  say,  the  occurrence 
of  genuine,  fully  developed  sarcinse  in  the  faeces  appears  to  be  but 
very  little  known.  They  are  not  infrequently  found  in  the  stools 
of  patients  suffering  from  gastrectasia.  Several  times  I  have  thus 
had  my  attention  directed  to  an  existing  gastrectasia  with  masked 
symptoms.  In  one  case,  however,  in  which  I  found  them  in  the 
evacuations  there  was  no  gastrectasia  present.  Usually  the  evacua- 
tions in  which  sarcinse  appeared  in  very  large  numbers  were  of  a 
diarrhoeal  nature,  and  the  question  therefore  suggests  itself  whether 
or  not  the  migration  of  sarcinae  en  masse  into  the  intestinal  canal 
can  not  give  rise  to  fermentative  processes  in  the  latter.  As  already 
remarked,  sarcina  intestini  in  no  wise  differs  from  the  sarcina  ventri- 
cuh.  As  in  the  latter  we  also  find,  in  addition  to  well-formed,  brown- 
ish yellow  or  lighter  coloured  bundles,  those  small  coccous  forms 
whose  constriction  is  indicated  only  by  a  loose  cementing  mem- 
brane. Like  the  sarcina  ventriculi,  the  sarcina  intestini  also  shows 
a  distinct  cellulose  reaction  with  iodin  and  chlorid  of  zinc  solution. 

{d)  Bacteria. — Undoubtedly  bacteria  form  the  gi-eater  percent- 
age of  the  micro-organisms  occurring  in  the  intestines,  or  rather  in 
the  fgeces.  They  consist  both  of  micrococci  and  bacilli.  Accord- 
ing to  von  Jaksch,  thin  stools  as  a  rule  contain  more  bacilli  and  firm 
ones  more  micrococci.     Some  of  these  organisms  are  motile. 


120 


DISEASES   OP  THE   INTESTINES 


1.  Bj  far  the  most  numerous  are  those  bacilli  first  described  by 
Escherich  as  belonging  to  the  group  of  bacterium  coli.  They  are 
quite  thick,  short  rods,  in  part  motile  and  partly,  immobile;  in 
appearance  and  growth  upon  most  nutritive  media  they  very  much 
resemble  the  typhoid  bacilli.  Unlike  the  typhoid  baciUi,  they  do 
not  curdle  sterile  milk  and  develop  gases  (CO2  and  II)  in  nutritive 
media  containing  sugar.  Their  size  varies  widely,  ranging  between 
0.5  and  3yLt. 

Careful  study  of  this  variety  of  bacteria  has  shown  that  they 
are  really  made  up  of  several  groups  resembling  one  another,  and 


Fig.  17. — Fj:ces  from  a  Case  or  Chronic  Enteritis,  showing  Sarcin.e. 
A,  starch  granule  ;  K,  fractured  triple  phosphate  crystal ;  M,  muscle  übres ;  E^  epithelial 
cells  ;  B,  goblet  cells;  P.  vegetable  cells  and  fibres.     (Original  observation.) 

which,  as  it  appears,  can  merge  from  one  into  the  other,  thus  per- 
mitting the  formation  of  pathogenic  organisms  from  innocent  sap- 
rophytes. Thus  a  large  number  of  diseases  have  already  been 
observed  in  which  it  is  suspected  that  the  bacteriuni  coli  plays 
an  important  role — e.  g.,  cholecystitis  and  cholangitis,  appendicitis, 
acute  dysentery,  peritonitis,  etc. 

The  addition  of  one  per  cent  of  iodid  of  potash  to  the  culture 
media,  as  advocated  several  years  ago  by  Elsner,^^  but  more  particu- 
larly the  well-known  Widal's  test,**'  enables  us  to  distinguish  typhoid 
bacilli  from  the  colon  and  other  bacilli. 


EXAMINATION   OP   THE    P^CES  121 

2.  Bacillus  Siibtilis  (Hay  Bacillus). — This  bacillus,  first  observed 
in  the  faeces  by  N'othnagel,  is  very  often  met  with  under  normal 
as  well  as  pathological  conditions.  It  forms  either  long,  motile  fil- 
aments with  spores,  or  isolated  bacilli  with  spores,  or,  finally,  groups 
of  spores.  It  is  readily  recognised  by  its  thick  contours  as  well  as 
by  its  strongly  refractive  spores.  It  stains  yellow  or  yellowish 
brown  with  Lugol's  solution.     It  has  no  special  significance. 

3.  Bacterium,  Lactis  JErogenes. — These  are  thick,  short  rods, 
1-2/A  in  length  and  0.5/a  in  width.  They  are  immotile.  They  are 
characterized  by  their  property  of  causing  milk  to  curdle  and  to 
ferment  with  the  formation  of  gas  within  sixty  hours.  On  potatoes, 
also,  the  bacterium  lactis  forms  gases.  Besides  milk  sugar,  they 
also  cause  cane  sugar  to  ferment.  It  is  possible  that  owing  to  its 
active  gas-forming  properties  the  bacterium  lactis  plays  an  impor- 
tant part  in  the  etiology  of  meteorism ;  but  of  this  we  know  noth- 
ing certain. 

4.  Bacillus  Putrificus  Coli  (Bienstock). — These  are  slender 
rods  about  3/*  in  length,  which  frequently  form  long  threads.  The 
spores  are  marginal,  and  develop  at  one  or  both  ends ;  if  at  one  end 
only,  they  give  the  bacillus  a  drumstick  appearance.  The  bacil- 
lus, especially  in  the  presence  of  air,  causes  a  rapid  decomposition 
of  albumin  with  the  formation  of  ammonia,  amin  bases,  amido- 
fatty  acids,  tyrosin,  phenol,  indol,  etc.  I  have  very  often  observed 
the  bacillus  in  stomach  contents  as  well  as  in  fseces,  but,  unlike 
Bienstock,  would  not  consider  it  as  a  regular  parasite  of  the  faeces. 

5.  Organis7ns  that  Stain  Blue  with  lodin. — Nothnagel  has  ob- 
served a  number  of  micro-organisms  which  stain  blue  with  iodin, 
and  he  regards  one  variety  as  identical  with  the  Clostridium  huty- 
ricum  of  Prazmowski.  The  bacillus  butyricus  (Fig.  18)  forms  rods 
from  3/i  to  10/x  in  length  and  Ifx  in  width,  and  frequently  occurs  in 
chains.  It  is  sometimes  said  to  form  long  filaments  which  are  quies- 
cent sometimes,  at  other  times  mobile.  Usually  the  bacillus  butyricus 
is  lemon-  or  lozenge-shaped  and  forms  large  clusters.  It  gives  a  very 
pronounced  iodin  reaction.  The  bacillus  is  anaerobic.  It  causes 
an  active  fermentation  of  starches,  dextrin,  sugar,  lactates,  and  cel- 
lulose. The  bacillus  butyricus  is  very  probably  the  chief  agent  in 
the  formation  of  butyric  acid  and  of  gases  in  the  intestines.  Ac- 
cording to  von  Jaksch,  with  whom  I  fully  agree,  the  bacillus  buty- 
ricus is  found  in  especially  large  numbers  in  pathological  conditions 
of  the  intestines.  In  almost  every  normal  stool  we  find  it  in 
smaller  numbers.     It  does  not  have  any  pathological  significance. 


122  DISEASES  OF  THE  INTESTINES 

The  pathogenic  organisms  occurring  in  the  faeces  include  the 
cholera,  typhoid,  and  tubercle  bacilli.  Since  a  work  like  the  pres- 
ent one  can  not  include  a  discussion  of  the  acute  infectious  diseases, 
the  tubercle  hacillus  is  the  onlj  one  we  shall  speak  about. 


Fig.  18.— Bacillus  bütyricus  {Clostridium  hutyricum)  stained  with  Iodin. 
(Original  observation.) 

Assuming  its  morphology  to  be  well  known,  we  would  simply 
say  regarding  its  demonstration,  that  the  technic  differs  in  no 
manner  from  that  of  sputum  examinations,  and  it  is  entirely  super- 
fluous to  enter  here  into  the  details  of  that  procedure.  As  to  the 
diagnostic  significance  of  tubercle  bacilli  in  the  fseces,  it  may  be 
summed  up  as  follows :  It  is  conclusive  of  a  tubercular  process  in 
the  intestines  when  we  know  positively  that  the  material  examined 
comes  directly  from  the  intestines — as,  for  example,  in  tubercular 
rectal  ulceration.  Otherwise  the  question  of  intestinal  tuberculo- 
sis must  remain  in  doubt. 

The  diagnosis,  intestinal  tuberculosis,  can,  however,  be  made 
with  certainty  where  there  is  an  entire  absence  of  sputum,  and 
tubercle  bacilli  constantly  appear  in  stools  that  are  of  a  thin,  bloody, 
or  purulent  character. 

Cocci  are  also  found  in  the  fseces,  though  not  as  frequently  as 
bacilli.     Since  they  are  of  much  less  practical  importance,  we  shall 


EXAMINATION  OF   THE   F^CES 


123 


refrain  from  their  discussion,  referring  the  reader  to  Mannaberg's 
able  description  in  Nothnagel's  work  on  Intestinal  Diseases. 

6.  Crystalline  Bodies. — These  may  be  organic  or  inorganic,  and 
are  seen  very  often  in  the  faeces.  With  the  exception  of  the  biharj 
concrements  previously  mentioned  (see  page  111),  the  diagnostic 
importance  of  crystalline  bodies  is  very  slight.  Since  they  may 
be  mistaken  for  other  similar  substances  it  is  necessary  to  be  able 
to  recognise  them.  The  follovring  are  the  principal  crystalline 
bodies  which  come  into  consideration : 

io)  HcBmatoidin  Crystals. — Yon  Jaksch  has  observed  these  in 
long-continued  catarrhs  follovidng  stasis,  and  also  in  many  cases  in 
which  intestinal  hsemorrhages  had  but  a  short  time  previously 
occurred.  Usually  hsematoidin  shows  an  indistinct  crystalline  struc- 
ture ;  the  crystals  are  in  part  free  and  in  part  embedded  in  a  lustre- 
less, mucoid  mass.  I  have  never  been  able  to  find  the  bodies  men- 
tioned by  von  Jaksch.  ^° 

(h)  Cholesterin. — It  is  extremely  rare  to  find  Cholesterin  pres- 
ent as  fully  formed  rhombic  plates.  This  appKes  as  well  to  normal 
as  to  pathological  stools.  Only  once  after  the  administration  of 
nutritive  enemata  have  I  seen  them  in  large  quantities.  ]^othnagel 
has  seen  them  after  nutritive  rectal  enemata  of  peptone,  wine,  and 
eggs.  This  author  quite  correctly  calls  attention  to  the  very  decep- 
tive similarity  between  fragments  of  triple  phosphates  and  Choles- 
terin scales.  Indeed,  the  resemblance 
is  so  close  that  I  have  frequently 
only  learned  my  error  through  ob- 
taining a  negative  Cholesterin  reac- 
tion. Cholesterin  also  undoubtedly 
appears  in  normal  faeces  in  an  amor- 
phous form ;  neither  form  has  any 
diagnostic  significance. 

(c)  Charcot- Ley  den  Crystals  (Fig. 
19). — These   are   by   no   means  ex- 
tremely  rare.      They    are   identical 
with  the  crystals  found  in  asthmatic 
sputum.    In  the  same  specimen  they 
may  vary  very  much  in  size.     Some- 
times they  can  be  distinctly  seen  only  with  the  highest  power  lenses. 
They   are   insoluble   in   alcohol,  ether,  and  chloroform,  but   very 
soluble  in  hydrochloric  acid  and  alkaline  solutions.     This  permits 
of  their  ready  distinction  from  fatty  acid  crystals.     They  stain  with 


Fig.  19. — Chaecot-Leyden  Crystals 
FROM  F^CES.     (Original   observation.) 


^1^24  DISEASES   OF  THE  INTESTINES 

carmin,  and  can  then  be  preserved  for  a  long  time.  ISTothnagel  ^ 
has  observed  their  aj^pearance  under  most  varied  conditions — viz., 
reconvalescence  from  typhoid,  typhoid  at  the  height  of  the  disease, 
phthisis,  in  dysenteric  disturbances  of  the  large  intestines,  in  a 
rachitic  child  with  fii'm  stools,  and  in  a  child  with  profuse  evacua- 
tions resulting  from  chronic  catarrh  of  the  large  and  small  intes- 
tines. Perroncito*^  and  Bäumler  "^  first  discovered  the  crystals  in 
persons  suffering  from  anchylostomal  disease.  This  was  the  status 
of  the  question  when  Leichtenstern,  in  1892,  called  attention  to  the 
coincident  occurrence  of  these  crystals  with  various  intestinal  para- 
sites (ascaris,  anchylostomnm,  trichocephalus,  oxyuris,  taenia,  etc.), 
and  stated  that  entozoa,  whatever  be  theh-  nature,  were  the  most 
frequent  cause  of  the  formation  of  Charcot-Leyden  crystals  in  the 
intestines,  and  of  their  subsequent  appearance  in  the  fseces.  From 
this  it  follows,  therefore,  that  the  crystals  possess  great  diagnostic 
value ;  if  found  in  the  fseces  we  may  with  the  greatest  probability, 
perhaps  certainty,  conchide  that  tTie  patient  in  question  is  suffering 
from  intestinal  entozoa  of  some  hind  (Leichtenstern  ^). 

Conversely  their  absence  does  not  in  any  manner  exclude  ento- 
zoa. Leichtenstern  based  his  views  on  the  significance  of  the 
coincidence  of  the  Charcot-Leyden  crystals  and  entozoa,  especially 
upon  the  fact  that  at  autopsies  he  was  always  able  to  find  them 
in  those  portions  of  the  intestines  in  which,  from  experience,  we 
know  the  parasites  in  question  are  usually  found.  In  anchylos- 
tomiasis,  in  particular,  these  crystals  are  found  with  such  con- 
stancy that  he  states  ttiat  they  are  distinctly  pathognomonic  of  that 
disease.  Strange  to  say,  little  attention  has  been  paid  to  this 
important  discovery  of  so  great  a  clinician  as  Leichtenstern,  who 
has  made  excellent  researches,  esj^ecially  regarding  entozoa.  The 
question  has  only  been  discussed  in  Roesen's  dissertation  ^,  where, 
after  an  examination  of  seventeen  cases  of  entozoa,  an  entirely 
negative  result  was  reached.  My  own  experience  in  the  matter 
is  too  slight  to  demand  recognition,  but  from  the  study  of  one  case 
I  have  gained  the  impression  that  the  value  ascribed  to  them  by 
Leichtenstern  is  correct. 

The  case  in  question  was  that  of  a  gentleman  thirty-six  years  old,  who  suf- 
fered from  chronic  catarrh  of  the  large  intestines,  and  whose  stools  I  used  fre- 
quently to  examine  very  carefully.  During  one  examination  I  found,  in  the 
mucous  portions  of  the  stool,  Charcot-Leyden  crystals  both  of  moderate  and 
very  large  size.  Although  not  attaching  much  importance  to  my  observation, 
I  took  note  of  it,  and  upon  repeated  examinations  the  same  condition  was 
observed.     After  three  or  four  weeks  the  patient  brought  me  taenia  proglottids, 


EXAMINATION   OF   THE   F^CES 


125 


whereupon  a  taenia  mecliocanellata  was  readily  removed.     In  spite  of  most 
careful  examination  tapeworm  eggs  could  never  be  found. 

This  case  needs  no  further  comment.*  Leichtenstern's  discovery 
is  certainly  worthy  of  greater  attention  than  it  has  heretofore 
received. 

{d)  Fatty  Acids  and  Fatty  Soap  Crystals. — We  have  ah-eady 
touched  upon  the  most  important  points  in  this  connection  (pages 
115  and  116).     We  here  wish  to  add  that  the  opinion  expressed 


Fig.  20.^Yellow  Calcium  Salts  feom  F^ces. 
In  some  the  concentric  arrangement  of  the  layers  is  well  seen.    (Original  observation.) 

by  Gerhardt  ^^  a  long  time  ago,  that  the  crystalline  bodies  occurring 
in  acholic  stools  might  be  tyrosin  crystals,  has  been  wholly  refuted 
by  the  investigations  of  Oesterlein  ^^,  Stadelmann  ^^,  Fr.  Müller  ^^ 
and  von  Jaksch  '*'. 

{e)  Phosphate  of  Calcium.— This  occurs  in  the  faeces  as  neutral 
phosphate  of  calcium  and  as  yellow  calcium  salts.  The  former  con- 
sists of  small  or  large  wedge-shaped  bodies,  arranged  for  the  most 

*  It  struck  me  as  strange  that  when  entozoa  eggs  were  present  the  crystals  were 
freqiiently  missing.  Besides  numerous  eases  of  taenia,  ascaris,  and  oxyuris  under 
my  own  observation,  I  would  also  mention  a  case  of  trichocephalus  dispar  in  which 
Charcot-Leyden  crystals  were  vainly  looked  for  repeatedly  by  both  my  assistants 
and  myself. 


^26  DISEASES   OP   THE  INTESTINES 

part  in  groups  with  converging  apices.  This  variety  does  not 
absorb  bile.  Yellow  calcium  salts  (Fig.  20)  (whose  acid  has  not  yet 
been  determined)  usually  assume  irregular,  oval,  or  circular  forms. 
They  are  frequently  fissured,  and  in  some  cases  are  arranged  in  con- 
centric layers.  The  yellow  colour  comes  from  imbibition  of  bile, 
JSTeither  form  has  any  diagnostic  significance. 

{f)  Oxalate  of  Calcium. — This  occurs  in  the  well-known  en- 
velope form.  The  crystals  may  be  small  or  large.  They  are 
found  especially  in  patients  under  largely  vegetable  diet.  These 
crystalline  bodies  are  met  with  in  normal  as  well  as  in  pathological 
stools. 

{g)  Ammonium-magnesium  Phosphates  (Triple  Phosphates). — 
These  crystals  are  one  of  the  most  frequent  crystalline  elements  of 

normal  or  pathological  stools,  espe- 
cially fluid  stools.  They  appear 
most  frequently  in  the  well-known 
coffin  -  cover  shape,  more  rarely 
feather- shaped.  The  coffin-cover 
fragments  frequently  show  tears 
and  fractures  (Fig.  lY),  and  thus 
may  occasionally  resemble  Choles- 
terin crystals.  The  solubility  of  the 
triple -phosphate  crystals  in  acetic 
acid  enables  us  to  avoid  error  in 
diagnosis.    They  have  no  diagnostic 

Fig.    21. — Bismuth    Crystals   fkom  VaiUe. 

F^cEs.    (Original  observation.)  (A)  Sulphate  of  Calcium^. — The 

appearance  of  sulphate  of  calcium 
in  the  faeces  is  said  to  be  extremely  rare.  I  have  never  seen  it  in 
the  dejections  themselves,  but  once  by  the  addition  of  sulphuric 
acid  to  faeces  obtained  some  very  pretty  sulphate  of  calcium 
needles  in  the  sediment,  which  consisted  principally  of  bilirubin- 
calcium. 

(^)  Bismuth  Crystals. — Yery  soon  after  administration  of  bis- 
muth, irregular  shaped,  rhombic,  dark  brown  or  black  crystals  are 
excreted  (Fig.  21).  Until  recently  these  have  been"  regarded  as 
sulphate  of  bismuth,  but,  as  previously  mentioned,  Quincke  showed 
that  they  consist  of  bismuth  oxydyl. 


EXAMINATION   OP   THE  FAECES  127 


LITERATURE 

1.  Fleischer.     Lehrbuch  d.  inneren  Medicin,  Bd.  ii,  2te  Hälfte,  S.  1139. 

2.  Quincke.     Münchener  med.  Wochenschr.,  1896,  No.  36. 

3.  Quincke  u.  Roos.     Berl.  klin.  Wochenschr.,  1893,  No.  45. 

4.  Boas.     Deutsch,  med.  Wociienschr.,  1896,  No.  14. 

5.  Nothnagel.      Beiträge  zur  Physiologie  u.   Pathologie  des  Darms,  Berlin, 

1884. 

6.  Ad.  Schmidt.     Zeitschr.  f.  klin.  Medicin,  1897,  Bd.  xxxii,  Heft  3  u.  4. 

7.  Pariser.     Deutsch,  med.  Wochenschr.,  1893,  No.  41. 

8.  J.  Kaufmann.     New  Yorker  med.  Wochenschr.,  November,  1895. 

9.  Blauberg.    Experimentelle u.  kritische  Studien  über  Säuglings-fäces,  u.  s.w., 

etc.,  Berlin,  1897,  S.  37,  u.  f. 

10.  von  Jaksch.     Klinische  Diagnostik,  4te  Aufl.,  S.  277. 

11.  von  Jaksch.     Ibid.,  S.  278. 

12.  Hoppe-Seyler — Thierfelder.     Handbuch  d.   physiolog.  u.  patholog. -chem- 

ischen Analyse,  5te  Aufl  ,  S.  479. 

13.  Biedert.     Jahrbuch  für  Kinderheilk.,  1878,  1879,  u.  1881. 

14.  Demme.     12ter    Jahresbericht    des    Jenner'schen   Kinderspitals   in   Bern, 

1874. 

15.  Fr.  Müller.     Zeitschr.  f.  klin.  Med.,  1887,  Bd.  xii,  S.  45-113.     (Here  will 

also  be  found  a  resume  of  previous  literature.) 

16.  Abelraann.     Inaug.-Dissert.,  Dorpat,  1890. 

17.  Saudmeyer.     Zeitschr.  f.  Biologie,  1895,  Bd.  xxxi,  S.  12. 

18.  Teichmann.     Inaug.  Dissert.,  Breslau,  1891. 

19.  Bamberger.     Die  Krankheiten  d.  ChylojDöetischen  Apparatus.     Virchow's 

Handbuch,  Bd.  vi. 

20.  Gerhardt.     Zeitschr.  f.  klin.  Med.,  Bd.  vi,  1883. 

21.  Nothnagel,  loc.  cit.,    S.    127,  and  Die  Erkrankungen  d.  Darmes  u.   Peri- 

toneum, S.  17. 

22.  Berggrün  u.  Katz.     Wiener  klin.  Wochenschr.,  1891,  S.  158. 

23.  Pel.     Centralbl.  f.  klin.  Med.,  1887,  S.  297. 

24.  H.  Weber.     Berl.  klin.  Wochenschr.,  1893,  No.  19. 

25.  A.  Schmidt.     Verhandlungen  d.  Congresses  f.  innere  Medicin,  1895. 

26.  Fleischer.     Lehrbuch  der  inneren  Medicin.     2ter  Th.,  2te  Hälfte,  1896,  S. 

1160. 

27.  Bunge.      Lehrbuch    d.    physiolog.    u.   patholog.    Chemie,    Leipzig,    1887, 

S.  192. 

28.  Leo.     Diagnostik  d.  Krankheiten  d.  Bauchorgane,  1895,  2te  Aufl.,  S.  348. 

29.  von  Jaksch.     Zeitschr.    f.  physich    Chemie,  Bd.   xii,  S.    116,   u.  Klinische 

Diagnostik,  4te  Aufl.,  S.  286. 

30.  Minich.     Berl.  klin.  Wochenschr.,  1894,  No.  8. 

31.  Leichtenstern.     Penzoldt-Stintzing  Handbuch  d.  speciellen  Therapie,   Bd. 

iv,  Abth.  vi,  15,  S.  206. 
33.  Herz.     Centralbl.  f.  klin.  Medicin,  1892,  p.  883. 
33.  Friedreich.     Krankheiten  des  Pankreas  in  von  Ziemssen's  Handbuch  d. 

spec.  Pathol,  u.  Therapie,  Bd.  viii. 


128  DISEASES  OP  THE   INTESTINES 

34.  Boas.     Diagnostik  u.   Therapie  d.  Magenkrankheiten,   Bd.  i,  4te  Aufl.,  S. 

281,  Fig.  26. 

35.  Rieder.     Deutsch.  Arch.  f.  klin.  Med.,  1898,  Bd.  lix,  H.  3  u.  4,  S.  444. 

36.  Sven  Akerlund.     Arch.  f.  Verdauungskrankheiten,  Bd.  i,  S.  396  u.  f. 

37.  Nencki,  Macfadyen  u.  Sieber.     Arch.  f.  experiment.  Pathologie  u.  Pharma- 

cologic, Bd.  xxviii,  S.  311-350. 

38.  Thierfelder  u.  Nuttal.     Zeitschr.   f.    physiol.   Chemie,  Bd.    xxi,   1895,    S. 

109-129,  and  Bd.  xxii,  1896,  S.  62-73. 

39.  Eisner.     Zeitschr.  f.  Hygiene,  Bd.  xxi,  8.  25,  1895. 

40.  Widal.     Semaine  medicale,  1896,  No.  33. 

41.  Perroncito.     Revista  della  Accademia  di  Torino,  II  Morgagni,  1881.     Cen- 

tralbl.  f.  d.  medicin.  Wissenschaften,  1881. 

42.  Bäumler.     Correspondenzbl.  f.  Schweizer  Aerzte,  liter  Jahrg.,  1881,  No.  1. 

43.  Leichtenstern.     Deutsch,  med.  Wochenschr.,  1892,  No.  25. 

44.  L.  Roesen.     Inaug. -Dissert.,  Bonn,  Crefeld,  1893. 

45.  Oesterlein.     Mittheilungen  a.  d.  med.  Klinik  in  Würzburg,  Bd.  i,  1885. 

46.  Stadelmann.     Deutsch.  Arch.  f.  klin.  Med.,  Bd.  xl,  S.  373,  1887. 


CHAPTEE  Yl 

THE  DIAGNOSTIC  VALUE   OF  THE  EXAMINATION  OF   THE 
STOMACH  CONTENTS  IN  INTESTINAL  DISEASES 

In  the  diagnosis  of  difficult  intestinal  diseases  an  analysis  of  the 
stomach  contents  is  sometimes  very  important,  or  may  even  be 
decisive.  In  the  first  place,  it  enables  ns  to  exclude  diseases  of 
the  stomach  itself.  Thus,  for  example,  if  we  find  a  poorly  defined 
tumour,  from  whose  location  alone  it  would  be  impossible  to  say 
whether  it  belongs  to  the  stomach,  the  intestines,  or  the  omentum, 
and  where,  in  addition,  there  are  general  evidences  of  a  serious  dis- 
eased condition,  the  finding  of  normal  stomach  contents  would  in  all 
probability  speak  against  gastric  cancer.  On  the  other  hand,  abnor- 
mal stomach  contents  does  not  signify  absence  of  the  disease  of  the 
intestines.  As  an  illustration  of  this  by  no  means  "  rare  complica- 
tion," I  may  cite  a  very  interesting  case  reported  by  Pulawski^  in 
which  the  clinical  picture  was  that  of  a  dilatation  of  the  stomach  and 
a  tumour  in  the  epigastrium,  while  the  autopsy  revealed  a  primary 
cancer  of  the  csecum.  The  gastric  tumour  felt  was  occasioned  by 
an  aggregation  of  carcinomatous  lymphatic  glands  which  com- 
pressed the  pylorus  and  caused  a  stenosis.  The  mucous  membrane 
of  the  stomach  was  entirely  normal.  The  reverse  of  this  case  is 
more  frequently  met  with — i.  e.,  a  gastric  tumour  becomes  displaced 
and  simulates  an  intestinal  neoplasm.  Here,  at  times,  examination 
of  the  gastric  contents  may  clear  up  the  diagnosis.  What  has 
always  struck  me  as  remarkable,  and  what  also  speaks  for  the  diag- 
nostic value  of  these  examinations,  is  the  fact  that  in  cancer  of  the 
intestines,  excepting  where  the  tumour  is  very  near  to  the  pylorus, 
the  gastric  secretions  may  still  be  normal  even  in  the  most  extreme 
stage  of  cachexia.  Examination  of  the  stomach  contents  may  also 
give  conclusive  evidence  for  the  diagnosis  of  a  stenosis  ielow  the 
duodenum.  It  can,  however,  only  indicate  the  existence  of  a  ste- 
nosis, the  nature  of  which  must  be  determined  by  other  means.  In 
these  cases  the  stomach  contents  are  always  bile  tinged,  especially  in 

129 


130  DISEASES   OF   THE  INTESTINES 

the  fasting  state.  I  was  the  first  to  show  that,  besides  bile,  pan- 
creatic, and  very  probably,  too,  intestinal  secretion,  pass  into  the 
stomach.  Hence  we  may  sometimes  observe  the  paradox,  duodenal 
digestion  occurring  within  the  stomach.  This  can  happen  only  where 
the  gastric  secretion,  as  is  frequently  the  case,  becomes  weakened  or 
entirely  suppressed  through  the  action  of  the  intestinal  fluids,  espe- 
cially of  the  bile.  As  has  already  been  shown  on  page  44,  when  the 
gastric  juice  remains  sufiiciently  acid  no  variations  from  the  nor- 
mal occur.  We  may  even  find  an  alternating  reaction  of  the  gastric 
contents,  according  as  intestinal  or  gastric  factors  predominate. 
Cohn,  Kiegel,  Hochhaus,  Schule,  Herz,  and  I,  have  published 
examples  of  this  last-named  condition. 

The  presence  of  pancreatic  juice  in  the  stomach  can  be  readily 
demonstrated  by  its  tryptic  action.  Its  demonstration,  I  believe, 
might  be  of  importance  in  determining  the  etiology  of  a  stenosis, 
for  with  a  palpable  tumour  in  the  region  of  the  ascending  portion 
of  the  duodenum,  the  occurrence  of  pancreatic  ferments  in  the 
stomach  contents  would  s-peak  for,  and  the  absence  of  such  ferments 
against,  the  existence  of  a  pancreatic  tumour ;  still,  I  can  not  sup- 
port this  statement  by  actual  cases.* 

Besides  the  deeply  situated  duodenal  stenoses,  the  much  rarer 
ones  of  the  jejunum  can,  I  think,  also  be  diagnosed  through  exam- 
ining the  gastric  contents.  In  these  cases  the  latter  no  longer  con- 
tains pure  bile,  but  a  yellowish  brown,  slightly  feculent  material, 
which  has  the  appearance  and  composition  of  jejunal  chyme.  Care- 
ful examinations  of  this,  but  more  especially  its  constant  appearance 
in  the  stomach  contents,  should  give  us  a  clew  to  the  existing  con- 
dition, particularly  if  we  can  exclude  a  fistula  between  the  stomach 
and  the  small  or  large  intestines.  We  would  add  that,  unlike 
deeply  seated  duodenal  stenoses,  the  suprapapillary  variety  can  not 
be  diagnosticated  by  examinations  of  the  stomach  contents,  for  the 
latter  are  exactly  the  same  as  in  benign  or  malignant  pyloric  stenosis. 

In  some  cases  the  determination  of  the  acidity  of  the  stomach 
contents  may  be  imjjortant  for  the  diagnosis  of  an  intestinal  affec- 
tion— e.  g.,  in  the  differential  diagnosis  of  ulcer  of  .the  duodenum 
and  of  the  stomach.  Leube^  states  that  he  found  normal  acidity  of 
the  stomach  contents  in  a  case  of  duodenal  ulcer,  while,  from  the 
investigations  of  Jaworski  and  Riegel,  we  know  that  the  acidity  in 

*  It  is  well  worth  repeating,  although  obvious  to  one  well  acquainted  with  the 
subject,  that  the  finding  of  bile  once,  or  even  repeatedly,  in  the  gastric  contents  pos- 
sesses no  diagnostic  value. 


VALUE   OF  EXAMINATION  OF   THE   STOMACH   CONTENTS     131 

gastric  ulcer  is  very  often  increased.  Too  much  value,  however, 
must  not  be  attributed  to  this  symptom. 

Oppler^  has  lately  and  quite  correctly  directed  attention  to  the 
total  cessation  of  gastric  secretion  in  chronic  diarrhoeas,  a  condition 
which  has  more  of  a  practical  than  diagnostic  value.  As  I  can  state 
from  repeated  personal  experience  in  these  cases,  we  may  meet  with 
severe  forms  of  gastritis  with  entire  absence  of  all  the  secretive 
factors  (hydrochloric  acid,  pepsin,  and  rennet).  I  have  no  doubt 
that  a  distinct  connection  exists  between  the  anacidity  of  the 
stomach  and  the  chronic  diarrhoea  and  intestinal  catarrhs. 

The  condition  of  the  gastric  contents  indirectly  aids  us  in  under- 
standing certain  intestinal  disturbances,  among  others  the  chronic 
constipation  that  so  often  follows  atony  or  ectasia  of  the  stomach. 
In  like  manner,  in  displacements  of  the  stomach,  particularly  when 
well  marked,  we  can,  as  a  rule,  assume  that  a  displacement  of  the 
intestine,  especially  of  the  large  intestine,  exists.  The  methods  by 
which  these  intestinal  displacements  can  be  recognized  have  already 
been  described. 

LITERATURE 

1.  Pulawski.     Berl.  klin.  Wochenschr.,  1892,  No.  42. 

2.  von  Leube.     Specielle  Diagnose  innere  Krankheiten,  1889,  S.  274. 

3.  Oppler.     Deutsch,  med.  Wochenschrift,  1896,  No.  32. 


CHAPTER  YII 

THE   DIAGNOSTIC    VALUE    OF    URINARY  EXAMINATIONS   IN 
INTESTINAL    DISEASE 

The  examination  of  the  urine  is  just  as  important  in  diseases  of 
the  intestines  as  it  is  in  almost  all  other  internal  and  many  external 
diseases.  It  may  in  many  cases  substantiate  and  even  clear  up  the 
diao^nosis.  Thus,  to  cite  one  instance,  the  discovery  of  an  amyloid 
kidney  may  serve  as  a  useful  argument  for  the  existence  of  amyloid 
disease  of  the  intestines,  a  condition  very  difficult  to  diagnose.  An 
attempt  to  dwell  on  all  existing  relations  between  the  intestines  and 
the  urine  would  mean  an  account  of  almost  the  whole  pathology  of 
the  urine.  In  the  following  recapitulation  we  confine  our  remarks 
solely  to  the  clinical  connection  between  intestinal  diseases  and  cer- 
tain abnormal  substances  found  in  the  urine.  These  substances  in- 
clude : 

1.  The  jrroditcts  of  intestinal  putrefaGtion^  especially  of  albu- 
minous putrefaction,  the  greater  number  of  which,  as  we  know,  ap- 
pear in  the  urine  as  aromatic  combinations.  These  include  indoxyl- 
and  skatoxyisulphuric  acids,  as  well  as  the  ethereal  sulphuric  acids 
(skatoxyl,  parakresol,  and  phenol  ethereal  sulphuric  acids). 

From  the  fundamental  investigations  of  Jaffe  \  E.  Salkowski  ^, 
Baumann ^,  Brieger'*,  and  Senator^,  we  know  that  the  indoxyl- 
sulphuric  acid  of  the  urine  is  regarded  as  a  derivative  of  the  indol 
formed  within  the  intestinal  canal.  In  the  intestines  indol  is 
already  oxidized  to  indoxyl,  and  the  latter  combines  with  the  sul- 
phuric acid,  or  with  the  sulphates  derived  from  the  food.  Indoxyl- 
sulphuric  acid  (indicanj  appears  in  the  urine  in  the  form  of  the  last- 
mentioned  combination.  From  this  it  follows  that  indican  is  an 
entirely  normal  product  of  intestinal  metabolism,  and  that  only  its 
increase  is  to  be  considered  as  pathological.  "Whereas  the  nor- 
mal daily  excretion  of  indican  varies  from  5  to  20  milligrammes 
(Jaffe),  in  increased  intestinal  putrefaction  it  may  reach  100  to  150 
milligrammes.  Fr.  Müller^  and  Ortweiler ''^  very  correctly  con- 
133 


THE  DIAGNOSTIC  VALUE  OF  IJRINARY  EXAMINATIONS    133 

sider  as  necessary  for  increase  in  the  urinary  excretion  of  indican 
a  certain  percentage  of  albumin  within  the  intestines,  marked 
stagnation  of  the  intestinal  contents,  and  finally  a  certain  absorptive 
faculty  on  the  part  of  the  bowel.  According  to  the  animal  experi- 
ments of  Jaffe  (which  have  been  fully  verified  in  man),  increased 
excretion  of  indican  occurs  mainly  in  obstructions  of  the  small,  and 
to  a  less  extent  of  the  large,  intestines.  Nevertheless,  we  may  also 
have  an  increased  indican  excretion  in  stenoses  of  the  large  intes- 
tines associated  with  long-continued  putrefaction  of  their  contents. 
Should  suppuration  coexist,  the  indicanuria  will  equal  in  amount 
that  of  the  small  intestines. 

As  may  be  readily  seen,  increased  indicanuria  is  largely  depend- 
ent upon  intestinal  peristalsis ;  other  things  being  equal,  the  slower 
the  peristalsis  the  greater  will  be  the  amount  of  indican  in  the  urine, 
and  vice  versa.  The  more  putrefactive  products  carried  off  by  the 
intestines,  the  less  will  be  brought  to  the  kidneys.  But  this  rule 
holds  good  only  in  a  general  sense :  for  Jaffe,  Vries,  Ortweiler, 
and  von  Pfungen  (with  whom  ISTothnagel  agrees)  have  shown  that 
there  may  be  no  indicanuria  in  obstinate  constipation  of  the  worst 
type.  The  reason  very  probably  is  that,  in  consequence  of  increased 
desiccation  of  the  fseces,  few  putrefactive  products  are  absorbed, 
and  the  fseces  therefore  very  rapidly  undergo  further  decomposition. 

The  above  considerations  indicate  that  the  presence  of  indican 
in  the  urine  is  of  decisive  value  only  when  taken  in  connection  with 
all  other  clinical  symptoms.  Indicanuria  may  be  of  importance  in 
the  differential  diagnosis  between  stenoses  of  the  large  and  small 
intestines,  or  between  benign  and  malignant  pyloric  stenosis,  etc. 
The  almost  constant  increase  of  indican  in  suppurative  peritonitis 
is  also  important. 

Besides  indigo  blue  there  is  a  second  urinary  colouring  sub- 
stance, indigo  red  ("  indigrubin,"  Kosin  ^).  Rosenbach's  well-known 
reaction  depends  upon  its  presence.  As  shown  by  control  tests  of 
E.  Salkowski  ^,  C.  A.  Ewald  ^%  Abraham  ^\  Rumpel  and  Messter  ^% 
and  others,  Kosenbach's  reaction,  like  a  pronounced  indigo-blue 
reaction,  indicates  nothing  more  than  an  increase  in  the  excretion 
of  indigo — i.  e.,  albuminoid  putrefaction.  To  a  certain  degree,  the 
ethereal  sulphuric  acids  of  the  urine  are  indicative  of  putrefaction. 
As  with  indoxyl,  it  has  been  shown  that  albuminoid  putrefaction  of 
stagnating  intestinal  contents  is  also  an  important  factor  in  the  pro- 
duction of  the  etherial  sulphuric  acids  (E.  Salkowski,  C.  A.  Ewald, 
Baumann,  Käst  and  Baas).  A  second  undoubted  factor  is  disturb- 
10 


l^^  DISEASES  OF  THE  INTESTINES 

ances  in  function,  sucli  as  occur  in  ileus,  incarceration  of  the  small 
intestines,  lead  colic,  peritonitis,  intestinal  tuberculosis,  and  cholera. 
Finally,  Brieger's^^  investigations  have  shown  that  in  such  acute 
infectious  diseases  as  diphtheria,  scarlet  fever,  and  facial  erysipelas 
there  is  an  increase  of  ethereal  sulphuric  acids,  while  in  typhoid, 
recurrent  and  intermittent  fevers,  variola,  and  meningitis  there  is  a 
decrease. 

Increase  in  the  ethereal  sulphuric  acids  has  also  been  observed 
in  foul-smelling  and  putrid  processes  in  various  portions  of  the 
body.  Furthermore,  we  may  mention  that  even  in  healthy  persons 
the  amount  of  ethereal  sulphuric  acids  excreted  is  subject  to  great 
fluctuations,  and  also  that  very  much  depends  upon  the  nature  of 
the  food  ingested.  It  therefore  follows  that  the  excretion  of  the 
ethereal  sulphuric  acids  occurs  under  various  conditions ;  that  it  de- 
pends as  much  upon  their  formation  within  the  intestines  as  it  does 
upon  their  absorption ;  furthermore,  that  it  is  to  a  large  extent  de- 
pendent upon  the  diet,  and  that  even  normally  it  is  subject  to  the 
greatest  variations.  In  the  present  status  of  the  subject  it  would 
be  very  risky  to  form  any  positive  diagnostic  conclusion  from  an 
increased  excretion  of  the  ethereal  sulphuric  acids.  Only  where 
there  is  a  marked  abnormal  increase  can  any  conclusion  be  drawn, 
and  then  only  in  conjunction  with  other  signs. 

2.  Acetonuria  and  Diaceturia. — Fetters ^^  and  Kaulich^^  pointed 
out  the  connection  between  digestive  disorders  and  acetonuria. 
Later,  Litten  ^^  described  the  occurrence  of  acetonuria  in  dyspeptic 
conditions.  Acetonuria  in  diseases  of  the  digestive  tract  has 
been  most  carefully  studied  by  Lorenz ^''.  He  found  this  con- 
dition present  in  diseases  of  the  stomach,  as  well  as  in  the  greatest 
variety  of  intestinal  disorders — e.  g.,  gastro-duodenal  catarrh, 
gastro-enteritis,  intestinal  obstruction  (from  marked  coprostasis), 
teenia,  peritonitis,  and  perityphlitis.  As  fever  was  present  in  the 
last-named  conditions,  febrile  acetonuria  could  not  be  positively  ex- 
cluded. In  almost  all  these  cases,  in  addition  to  the  aceton,  diacetic 
acid  was  also  found.  At  present  no  diagnostic  significance  can  be 
attached  to  acetonuria. 

3.  Albuminuria. — Maixner^^  and  Pacanowski^^  first  called  atten- 
tion to  the  occurrence  of  an  enteric  peptonuria  (more  correctly 
albuminosuria),  and  Ilobitschek^°,  who  employed  improved  methods, 
confirmed  their  discovery ;  nevertheless,  the  doctrine  of  an  enteric 
albuminuria  rests  upon  a  very  weak  basis.  Chvostek  and  Stro- 
mayr's'^  recently  published  investigations  upon  the  occurrence  of 


THE  DIAGNOSTIC  VALUE  OF  URINARY  EXAMINATIONS    135 

alimentaiy  albuminosuria  in  ulcerative  intestinal  tuberculosis  are 
deserving  of  greater  attention.  A  few  hours  after  such  patients  had 
received  large  amounts  of  drj  peptones  or  of  somatose,  albumoses 
were  found  in  the  urine,  Devato's^^  and  Salkowski's^  methods 
being  employed  for  their  detection.  In  some  positive  cases  of 
ulcerative  intestinal  tuberculosis  albumoses  were  not  found,  so  that 
a  diagnostic  value  can  only  be  attached  to  a  positive  result  of  the 
test. 

LITERATURE 

1.  Jaffe.     Centralbl.  f.  d.  medicin  "Wissenschaften,  1872,  S.  481,  and  Virchow's 

Archiv,  Bd.  Ixx,  S.  73. 

2.  E.  Salkowski.     Bericht  d.  deutsch.  Chem.  Gesellschaft,  Bd.  ix,   S.  138  u. 

408. 

3.  Baumann.     Pflüger's  Archiv,  Bd.  xiii. 

4.  Baumann  u.  Brieger.     Zeitschr.  f.  physiol.  Chemie,  Bd.  iii,  S.  254. 

5.  Senator.     Centralbl.  f.  die  medicin.  Wissenschaften,  1877,  S.  357. 

6.  Fr.  Müller.     Mittheilungen  a.  d.  Würzburger  Klinik,  Bd.  ii,  S.  341. 

7.  Ortweiler.     Ibid.,  S.  153. 

8.  Rosin.     Virchow's  Archiv,  Bd.  cxxiii,  1891,  S.  519. 

9.  E.  Salkowski.     Berl.  klin.  Wochenschr.,  1889,  No.  26. 

10.  C.  A.  Ewald.     Ibid ,  1889,  No.  44. 

11.  Abraham.     Ibid.,  1890,  No.  27. 

13.  Rumpel  u.  Messter.     Centralbl.  f.  klin.  Med.,  1891,  S.  527. 

13.  Brieger.     Zeitschr.  f.  klin.  Med.,  1881,  Bd.  iii,  S.  468. 

14.  Petters.     Prager  Vierteljahrsschrift,  14.  Jahrgang,  1857. 

15.  Kaulich.     Ibid.,  17.  Jahrgang,  1860. 

16.  Litten.     Zeitschr.  f.  klin.  Med.,  Bd.  vii,  Supplementheft,  1882. 

17.  Lorenz.     Ibid.,  Bd.  xix,  1891,  S.  19. 

18.  Maixner.     Zeitschr.  f.  klin.  Med.,  Bd.  viii,  1884,  S.  534. 

19.  Pacanowski.     Ibid.,  Bd.  ix,  1885,  S.  428. 
30.  Robitschek.     Ibid.,  Bd.  xxiv,  1894,  S.  536. 

21.  Chvostek  u.  Strohmayr.     Wiener  klin.  Wochenschr.,  1896,  No.  47. 

23.  Devoto.     Zeitschr.  f.  physiol.  Chemie,  Bd.  xv,  Heft  5. 

33.  Salkowski.     Centralbl.  f.  d.  medicin.  Wissenschaften,  1894,  No.  7. 


GENERAL   THERAPEUTICS   OE 
INTESTINAL  DISEASES 

" Non  medicamentis  confidere  sed  therapiie." — von  Liebeemeistee. 


CHAPTEE  YIII 

THE   DIETETIC    TREATMENT    OF   INTESTINAL    DISEASES 

The  fundamental  principles  laid  down  in  the  general  section  of 
my  book  on  The  Diagnosis  and  Treatment  of  Diseases  of  the  Stom- 
ach apply  equally  to  the  general  dietetic  treatment  of  intestinal  dis- 
eases. To  avoid  repetition,  we  refer  the  reader  to  that  work.  Sev- 
eral of  the  rules  of  procedure  there  described — e.  g.,  those  for  the 
treatment  of  gastric  ulcer  and  acute  gastritis — may  with  slight 
changes  be  apj^lied  to  cases  of  ulcer  of  the  small  intestine  and  acute 
enteritis.  The  conditions  are,  however,  far  more  complicated  in 
many  other  intestinal  diseases.  According  to  the  pathological  con- 
dition in  the  intestines,  the  stomach  contents  must  have  a  varying 
influence  upon  the  intestinal  contents ;  these  latter  are  acted  upon 
by  three  distinct  secretions,  each  of  which  may  vary  in  its  effect 
upon  the  intestines.  Absorption  from  the  intestines  and  intestinal 
peristalsis  may  vary  considerably.  Some  excrementitious  substances 
from  the  blood  exert  an  undoubted  action  on  the  iutestines. 
ISTervous  and  vaso-motor  influences  can  hasten  or  retard  digestion. 
From  a  consideration  of  all  these  conditions  it  is  evident  that  intes- 
tinal digestion  is  a  very  complicated  process.  The  principles  of 
feeding  in  gastric  affections  are  based  to  some  extent  on  the  results 
gained  from  an  analysis  of  the  stomach  contents  which  can  be 
readily  obtained.  On  the  other  hand,  we  have  as  yet  no  satis- 
factory and  practical  general  method  of  obtaining  and  analyzing 
the  intestinal  contents.  Sometimes  an  idea  of  the  changes  which 
the  food  has  undergone  in  the  bowel  may  be  gained  from  an 
analysis  of  the  faeces.  Hence  the  pathologist  and  physiologist 
have  for  many  years  paid  great  attention  to  the  examination  of  the 
fseces. 

The  first  fundamental  fact  was  discovered  by  Eubner,  who 
showed  that  the  digestion  of  food  stuffs  depends  principally  upon 
their  chemical  and  physical  composition. 

139 


140  DISEASES  OF  THE  INTESTINES 

The  following  table  is  taken  from  Eubner's  ^  work 


Food  stuffs. 

■WEIGHT  OF  SAME 
IN  GRAMS. 

ABSORBED 

IN  PER  CENTS  OF 

Fresh. 

Dried. 

Dried 
substance. 

Albumin. 

Fat. 

Carbo- 
hydrates. 

Ash. 

Meat 

884 

984 

2,470 

2,490 

860 

1,360 

695 

750 

638 

600 

3,078 

3,880 

2,566 

376 

247 
315 
420 
753 
765 
626 
641 
780 
553 
521 
819 
406 
352 

95 
95 
92 
94 
95 
85 
96 
93 
96 
96 
91 
91 
85 
79 

97 
97 
94-99 
96 
81 
68 
83 
85 
93 
80 
83 
68 
82 
61 

95 

95 

95-97 

97 

94 
83 
91 
93 

96 
94 

94 

ioo 

100 
99 
89 
99 
97 
96 
99 
96 
92 
85 
82 

82 

Kp'CtS 

82 

Milk 

51 

Milk  and  cheese  . . 

White  bread 

Black  bread 

Macaroni 

Indian  corn 

Corn  and  cheese. . 
Rice 

74 
93 
64 

76 
70 
81 
85 

Peas 

68 

Potatoes 

84 

Cabbage 

81 

Carrots 

76 

This  table  is  very  instructive  in  that  it  shows  that  the  albumi- 
nous substances  contained  in  meat,  eggs,  and  milk  are  almost  totally 
used  up  in  the  intestines.  ISTone  of  the  vegetable  matters,  with  the 
exception  of  Indian  corn,  are  so  completely  absorbed.  Yery  little 
of  black  bread,  potatoes,  and  carrots  is  absorbed.  The  greater  paj-t 
of  the  carbohydrate  materials  is,  however,  absorbed  in  the  intes- 
tines. Thus  milk  loses  100  per  cent ;  white  bread,  macaroni,  In- 
dian corn,  rice,  and  peas  almost  as  much ;  potatoes  and  carrots  lose 
little  of  their  carbohydrate  matters  in  the  intestinal  canal.  Intes- 
tinal absorption  of  the  fatty  matters  is  also  very  active ;  thus  milk 
loses  very  much  of  its  fat,  as  do  also  meat,  eggs,  macaroni,  rice, 
potatoes,  cabbage,  and  carrots. 

The  digestibility  of  food  stuffs  can  be  further  heightened  by  the 
manner  of  preparing  them.  Thus,  according  to  Rubner,  Boeck, 
Praussnitz,  Weiske,  and  others,  72  per  cent  of  the  albuminous  mat- 
ters are  absorbed  in  the  intestine  from  boiled  peas  as  against  82  per 
cent  from  ground-up  peas,  and  68  per  cent  of  boiled  potatoes  as 
against  80  per  cent  of  mashed  boiled  potatoes.  The  addition  of 
spices  to  the  food  is  also  of  undoubted  benefit  in  this  respect.  The 
above-mentioned  figures  apply  only  to  healthy  persons.  Unfortu- 
nately, our  knowledge  of  the  digestibility  of  food  stuffs  in  diseased 
individuals  is  very  limited.  The  investigations  of  Fr.  Müller^,  so 
frequently  referred  to,  have  shown  that  in  intestinal  diseases  the 
absorption  of  fats  is  early  disturbed,  and  the  absorption  of  nitroge- 
nous matters  is  interfered  with  only  in  some  intestinal  catarrhs. 


THE  DIETETIC  TREATMENT  OF  INTESTINAL  DISEASES    141 

The  absorption  of  carbohydrates  is  almost  never  interfered  with, 
although  it  is  probable  that  some  of  the  carbohydrates  are  lost 
through  fermentative  processes  in  the  intestines. 

The  food  stuffs  exert  an  important  influence  upon  many  of  the 
intestinal  putrefactive  processes.  Thus  Eubner  ^  observed  that 
after  a  diet  of  bread  the  products  of  albuminoid  putrefaction  dis- 
appeared from  the  urine,  and  in  their  stead  there  appeared  a  butyric 
acid  fermentation. 

Hirschler  ^  demonstrated  that  a  direct  antagonism  existed  be- 
tween albumin  and  carbohydrate  putrefaction.  Ortweiler  ^  showed 
that  a  free  diet  of  carbohydrates  is  apt  to  be  followed  by  the  com- 
plete disappearance  of  indican  from  the  urine.  It  is  evident  that 
the  food  stuffs  vary  in  their  proneness  to  decomposition,  and  that 
in  disease  there  may  be  a  greater  or  less  tendency  for  the  occur- 
rence of  putrefactive  processes  of  the  albuminous,  carbohydrate, 
or  fatty  matters.  Unfortunately,  our  knowledge  of  the  principles 
of  dietetics  is  so  meagre  that  no  deductions  can  be  drawn  from  this. 

In  the  absorption  of  food  stuffs  from  the  diseased  intestine  an- 
other factor  is  of  importance,  viz.,  the  influence  exerted  by  the  food 
upon  the  intestinal  functions.  Thus,  for  example,  in  some  diseases 
of  the  intestines  milk  causes  constipation,  in  others  diarrhoea.  Eggs, 
to  take  another  example,  are  not  well  borne  in  diarrhoea,  but  are 
always  prone  to  cause  flatulence.  The  idea  that  some  substances 
are  easier  digestible  and  others  not  so  is  gradually  losing  many  ad- 
herents, for  we  are  gradually  coming  to  the  conclusion  that  the 
digestibility  of  foods  varies  in  each  individual  case.  This  illustrates 
the  uselessness  of  basing  our  dietetic  measures  solely  upon  the  diges- 
tibility of  various  foods.  Clinical  experience  must  teach  us  the 
principles  of  dietetics.  From  my  observations  and  those  of  others 
the  following  rules  may  be  laid  down : 

1.  In  a  number  of  intestinal  diseases  a  change  of  diet  is  un- 
necessary, or  may  even  be  harmful. 

2.  In  some  cases  special  dietetic  restrictions  are  directly  indi- 
cated, but  these  should  be  as  few  as  possible. 

3.  In  another  series  of  cases  an  abundant  heavy,  not  easily  diges- 
tible or  absorbable  diet  is  indicated. 

4.  The  general  aim  of  our  treatment  should  always  be  to  so 
manage  the  case  before  us  that  digestion  of  a  normal  diet  will 
always  occur  in  the  alimentary  canal  without  any  subjective  or  ob- 
jective disturbances.  Under  these  circumstances  only  can  the  case 
be  considered  cured. 


14:2  DISBASES  OF  THE  INTESTINES 

The  reasons  which  have  led  me  to  adopt  the  above  principles  of 
treatment  will  be  given  in  what  follows,  which  will  contain  a  gen- 
eral description  of  the  principles  of  feeding  in  diseases  of  the  intes- 
tines. For  simplicity  of  understanding,  intestinal  diseases  are  classi- 
fied *  as 

1.  Diseases  of  the  mucous  membrane  (ulcers  of  the  duodenum, 
jejunum  and  ileum,  acute  and  chronic  enteritis,  carcinoma,  intestinal 
ulcers  in  general). 

2.  Functional  disturbances  (increased  or  diminished  peristalsis). 

3.  Stenosis  or  occlusions. 

4.  Localized  peritonitis  (appendicitis) ;  diffused  peritonitis. 

5.  ISTeuroses. 

1.  Diseases  of  the  Intestinal  Mucous  Membeane 

In  diseases  of  the  mucous  membrane  the  principles  of  feeding 
are  similar  to  those  laid  do^vn  for  the  treatment  of  affections  of  the 
body  in  general — i.  e.,  rest  for  the  affected  part.  The  temporary 
withdrawal  of  all  foods  constitutes  the  greatest  possible  amount  of 
rest  for  the  digestive  tract,  and  one  that  is  often  followed  by  bril- 
hant  therapeutic  results.  This  method  comes  up  for  a  special  con- 
sideration in  acute  bleeding  from  the  stomach  or  intestines,  in  acute 
gastro- enteritis,  and  in  rebellious  forms  of  gastric  or  duodenal  ulcer- 
ation. The  importance  of  the  latter  disease  is  worthy  of  special 
consideration  in  this  place.  That  the  absolute  withdrawal  of  food 
is  the  best  therapeutic  measure  in  acute  intestinal  haemorrhage 
(exclusive  of  bleeding  from  haemorrhoids)  is  not  as  yet,  according 
to  my  experience,  generally  acknowledged.  I  emphasize  the  word 
absolute,  because  I  believe  that  in  these  cases  even  water  by  the 
mouth  is  harmful.  In  such  a  patient  the  physician,  and  especially 
the  relatives  and  friends,  are  but  too  apt  to  give  the  patient  large 
quantities  of  fluid  to  drink  to  compensate  for  what  has  been  lost 
by  the  bleeding — a  procedure  which  I  consider  absolutely  wrong. 
Food  should  not  be  given  by  the  mouth  until  twenty-four  to  thirty- 
six  hours  after  the  haemorrhage  has  ceased.  By  that  time  the 
bleeding  vessels  have  probably  been  closed  by  a  thrombus.  If  the 
weakness  of  the  patient  calls  for  immediate  feeding,  nutrient  ene- 

*  In  this  classification  it  may  occur  that  some  diseases  might,  during  their 
course,  come  under  another  heading  than  they  would  at  first ;  thus,  a  carcinoma 
of  the  intestines  might  be  at  first  considered  a  disease  of  the  mucous  membrane, 
later,  as  the  symptoms  of  obstruction  come  to  the  foreground,  as  a  stenosis.  The 
same  is  true  of  many  other  intestinal  affections. 


THE  DIETETIC  TREATMENT  OP   INTESTINAL   DISEASES    143 

mata  should  be  ordered.*  During  the  following  few  days  the 
patient  should  be  kept  on  a  fluid  diet.  After  eight  to  ten  days 
the  diet  may  be  gradually  increased  according  to  the  well-known 
plan  of  Leube. 

In  acute  hsemorrhage  from  the  large  intestines  (as  in  haemor- 
rhoids, dysenteric  ulcers,  and  neoplasms)  the  danger  of  profuse 
bleeding  is  not  great,  and  hence  the  entire  withdrawal  of  food  is 
unnecessary.  It  will  generally  suffice  to  restrict  the  patient  to  a 
soup  diet  for  a  few  days. 

In  chronic  bleedings,  which  are  apt  to  be  small  ones,  it  is  very 
important  so  to  arrange  the  patient's  diet  as  to  prevent  the  symptoms 
of  exhaustion  which  are  apt  to  appear.  The  choice  will  largely 
depend  upon  the  nature  and  character  of  the  illness.  In  the  spe- 
cial part  of  the  present  work  more  attention  will  be  paid  to  this 
subject. 

In  violent  haemorrhages  from  large  blood-vessels  (embolism  of 
the  mesenteric  artery,  rupture  of  varicose  veins,  etc.)  we  are 
usually  powerless.  Diet  has  but  little  influence  upon  these  haemor- 
rhages. 

The  treatment  of  acute  gastro-enteritis  or  enteritis  alone  is  far 
simpler.  In  these  afliections  the  loss  of  appetite  facilitates  the 
withdrawal  of  food.  In  very  acute  diarrhoeas  we  must  provide 
against  the  severe  thirst  which  is  so  apt  to  be  present,  by  giving  the 
patient  diluted  claret,  oatmeal  soups,  cocoa  boiled  in  water,  and  tea 
without  sugar.  In  chronic  duodenal  ulceration  the  same  diet  as  in 
gastric  ulcer  is  to  be  ordered.  The  patient  should  remain  in  bed 
for  several  weeks,  poultices  should  be  applied  to  the  abdomen,  and 
he  should  partake  of  a  bread -and-milk  diet.  This  diet  should  be 
continued  until  subjective  and  objective  sensitiveness  have  disap- 
peared, when  the  patient  should  abstain  for  a  long  time  from  inju- 
rious diet — that  is,  food  digested  with  difficulty  (ice  cream  and  iced 
dishes,  raw  fruit,  hard  bread,  all  kinds  of  cabbage) — and  improper 
drinks  (iced  drinks,  acid  fruit  juices,  carbonated  beverages). 

In  very  obstinate  forms  of  duodenal  or  jejunal  ulceration  the 
treatment  is  similar  to  that  of  gastric  ulceration — i.  e.,  abstinence 
from  all  food  for  ten  to  fourteen  days,  and  rectal  alimentation.  In 
nine  undoubted  cases  of  this  class  I  found  that  the  above-outlined 
treatment  was  always  sufficient. 

*  Concerning  the  composition  and  method  of  giving  nutrient  enemata,  see 
Boas,  Diagnosis  and  Treatment  of  Diseases  of  the  Stomach,  fourth  edition, 
Part  I,  p.  293. 


144  DISEASES  OF  THE  INTESTINES 

The  diet  in  chronic  enteritis  varies  greatly,  according  to  the  sit- 
uation, intensity,  extent,  and  duration  of  the  disease.  It  is  diffi- 
cult, therefore,  to  lay  down  any  general  rules,  and  we  will  limit 
ourselves  to  a  few  suggestions,  reserving  fuller  details  for  the  second 
part  of  this  work.  The  treatment  will  depend  mainly  upon  our 
being  able  to  «locate  the  intestinal  catarrh. 

Catarrhal  affections  of  the  small  intestines  call  for  a  particularly 
cautious  diet.  In  long-standing  diseases  it  is  clear  that  the  intesti- 
nal secretions  are  deficient  in  quality,  and  hence  can  not  act  in  a 
normal  manner  upon  the  chyme.  It  can  be  readily  understood  that 
if,  in  place  of  the  normal  strongly  alkaline  intestinal  juice,  a  weakly 
alkaline  one  containing  large  quantities  of  mucus  is  secreted  (in 
which  cases  the  acidity  of  the  chyme  is  not  sufficiently  neutralized), 
the  pancreatic  juice  will  be  acted  on  in  an  abnormal  manner.  In 
the  presence  of  the  strong  acidity  the  pancreatic  juice  loses  its  tryp- 
tic,  diastatic,  and  fat-splitting  properties ;  the  emulsification  of  fats 
is  delayed,  or  does  not  at  all  take  place ;  the  action  of  the  bile  is 
likewise  interfered  with  by  the  hyperacidity  of  the  small  intestines. 
Where,  as  is  usually  the  case  in  intestinal  catarrh,  there  is  diarrhoea, 
the  greatest  care  must  be  exercised  in  the  selection  of  a  suitable 
diet.  If  the  diet  does  not  contain  sufficient  nourishment,  the 
patient  may  suffer  from  a  transitory  loss  of  albumin.  JSTeverthe- 
less,  this  plan  must  be  carried  out.  The  more  numerous  the 
evacuations,  the  greater  is  the  need  for  restriction  of  the  diet.  In 
the  beginning,  gruel,  cocoa,  tea,  beef  tea,  nutrose,*  and  claret,  or 
cognac  diluted  with  water,  may  be  ordered  for  the  patient.  The 
diet  must  be  varied  according  to  the  number  and  consistency  of 
the  movements.  Regarding  a  diet  of  milk  and  eggs  in  diarrhoea, 
the  most  important  facts  have  already  been  given ;  as  the  patient 
improves,  an  egg  may  be  stirred  into  the  soup,  and  according  to 
the  manner  in  which  the  patient  stands  this  the  diet  can  be  still  fur- 
ther increased.  We  may  then  gradually  let  the  patient  take  milk. 
Its  effects  should  be  carefully  noted ;  very  often  it  will  have  to  be 
entirely  excluded.  It  is  obvious  that  all  substances  that  increase 
peristaltic  motion  (fruit,  cider,  certain  wines,  [organic]  acids,  honey, 
sugar)  must  be  avoided.  It  is  not  correct,  however,  as  is  still  often 
done,  to  give  general  instructions  according  to  the  above-mentioned 
principles.  Exact  instructions  as  to  the  diet  must  be  given  in 
treating  each  individual  case. 

*  In  all  diarrhoeal  conditions  somatose  must  be  avoided,  because  it  is  apt  to 
aggravate  them. 


THE  DIETETIC  TREATMENT  OF  INTESTINAL  DISEASES    145 

In  catarrh  of  the  large  intestine  dietetic  principles  are  quite 
different.  There  is  present  either  constipation,  or  constipation 
alternating  with  diarrhoea,  or  diarrhoea  alone.  In  the  last-named 
variety  the  diet  is  the  same  as  that  of  catarrh  of  the  small  intes- 
tines. In  the  other  forms  our  aim  should  be  to  regulate  the  move- 
ments without  injury  to  the  inflamed  intestinal  mucous  membrane. 
In  these  cases  digestion  in  the  stomach  and  the  small  intestines  is 
usually  normal,  and  therefore  the  patient  may  from  the  very  begin- 
ning be  placed  upon  a  full  and  nourishing  diet.  We  may  begin 
with  a  free  diet  (meat,  fish  well  prepared,  soft-boiled  eggs,  fat  such 
as  butter,  chicken  fat,  cocoa  butter).  Yegetables  in  puree  form  and 
carefully  prepared  pastry  may  also  be  allowed.  Conversely,  experi- 
ence has  shown  that  soups  tend  to  arrest  peristalsis  ;  they,  as  well  as 
other  physiological  astringents  (rice,  farina,  cocoa,  red  wine,  huc- 
kleberry wine,  etc.),  are  to  be  avoided.  Physiological  laxatives 
(honey,  milk,  sugar,  glucose,  grapes,  stewed  fruits,  and  sweet  pas- 
try) are  especially  to  be  recommended.  In  these  cases  milk,  and 
particularly  such  of  its  derivatives  as  contain  acids  (buttermilk, 
koumyss,  sour  milk),  may  be  employed  to  great  advantage.  We 
should  strictly  forbid  the  use  of  all  substances  which  from  experi- 
ence resist  all  action  of  the  intestinal  secretions,  such  as  the  cellu- 
lose of  cabbage,  beets,  and  root  vegetables,  as  well  as  indigestible 
seeds  which  are  contained  in  many  fruits  (huckleberries,  cranber- 
ries, currants,  and  gooseberries),  A  very  similar  diet  is  to  be 
ordered  in  that  form  of  intestinal  catarrh  that  manifests  itself  in 
diarrhoea  alternating  with  constipation,  for  here  the  con8ti]3ation 
must  be  looked  upon  as  the  predominant  and  primary  factor.  In 
these  cases  our  judgment  of  the  results  of  the  treatment  instituted 
should  not  be  governed  by  the  effect  upon  the  constipation  alone, 
but  from  the  appearance  of  the  evacuations,  and  particularly  from 
the  amount  of  mucus  contained  in  them.  At  the  same  time  the 
above-named  general  principles  must  not  be  lost  sight  of.  In  pri- 
mary catarrhs  of  the  lowermost  portion  of  the  intestine  (sigmoid 
flexure  and  rectum)  the  same  general  principles  also  apply. 

In  secondary  catarrh,  we  may  under  favourable  circumstances 
achieve  successful  results  by  removing  the  cause  of  the  congestion 
in  the  intestinal  blood-vessels.  Generally  we  will  have  to  content 
ourselves  with  a  symptomatic  treatment  of  the  intestinal  disturb- 
ances, following  the  above-mentioned  underlying  principles. 

The  dietetic  treatment  of  intestinal  ulcers  also  varies  much, 
according  to  their  nature  and  situation  and  the  influence  which  they 


146  DISEASES  OF  THE  INTESTINES 

exercise  upon  the  movements.  Tlius,  according  to  J^othnagel, 
ulcers  of  the  small  intestine  or  of  the  ascending  colon  only  cause 
diarrhoea  when  they  occur  simultaneously  with  other  conditions 
(catarrh,  amyloid  disease,  etc.),  while  ulcers  of  the  lower  division 
of  the  large  intestine  are  usually  accompanied  by  diarrhoea.  Natu- 
rally the  diet  in  ulceration  of  the  upper  portions  of  the  small  intes- 
tines will  have  to  be  a  very  cautious  but  highly  nutritive  one,  and 
in  ulcers  of  the  lower  portions  of  the  small  intestine  we  should  by 
all  means  avoid  all  irritation  of  the  mucous  membrane  from  indi- 
gestible food  masses.  For  the  rest,  the  condition  of  the  evacuations 
(consistency,  number,  admixtures  such  as  pus,  blood,  etc.)  will  have 
to  guide  us  in  the  choice  of  the  diet. 

As  regards  tumours,  the  malignant  ones  alone  require  special 
dietetic  measures.  We  will  have  to  take  into  consideration  the  pres- 
ervation of  the  patient's  life,  and,  if  possible,  the  improvement 
of  his  general  condition,  the  local  (intestinal)  damage  (secondary 
catarrh,  stenosis).  Since  our  dietetic  measures  will  ultimately  de- 
pend upon  these  complications,  they  will,  to  avoid  repetition,  be 
detailed  in  the  section  on  "  Intestinal  Stenosis  "  (Part  II). 

2.  Diet  in  Functional  Distuebances  of  the  Intestines 
{Iietardatio7i  or  A  cceleration  of  Peristalsis) 

Under  this  heading,  in  the  first  place,  we  include  habitual  con- 
stipation and  habitual  diarrhoea.  Both  conditions  may  be  accom- 
panying symptoms  of  other  diseases,  or  they  may  occur  as  inde- 
pendent functional  intestinal  disturbances ;  they  therefore  deserve 
to  be  discussed  separately.  In  the  second  portion  of  this  work  fur- 
ther consideration  will  be  paid  to  this  subject ;  in  the  present  place 
we  wish  to  discuss  the  dietetic  treatment  of  simple,  uncomplicated 
constipation  and  diarrhoea. 

In  habitual  constipation  the  diet  must  be  a  plentiful  as  well  as  a 
mixed  one,  and  should  contain  substances  that  are  known  to  stimu- 
late peristalsis.  Conversely,  as  already  stated,  dietetic  astringents 
must  be  avoided.  The  first  indication  is  frequently  disregarded. 
We  have  already  seen  that  foodstuffs  are  divisible  into  those  well 
utilized  and  those  poorly  utilized  by  the  economy.  The  first  group 
includes  all  fluids  and  substances  dissolved  in  them,  meat,  fish, 
wheaten  bread  and  the  like,  light  pastry,  etc.  The  second  group 
includes  those  foodstuffs  that  leave  more  or  less  of  an  indigestible 
residue — as,  for  example,  fruit,  rye  bread,  cabbage,  potatoes,  salad, 
and  other  vegetables  rich  in  cellulose. 


THE  DIETETIC  TREATMENT  OF  INTESTINAL  DISEASES    I47 

The  main  feature  in  the  treatment  of  habitual  constipation  is 
the  employment  of  this  last-named  variety  of  foodstuffs.  Were  a 
vegetable  diet  as  nutritious  as  a  mixed  diet,  and  were  its  exclusive 
employment  not  frequently  associated  with  objective  (gastric  and 
intestinal  dilatation)  and  subjective  disturbances  (abnormal  flatu- 
lence), it  would  be  the  ideal  one  in  constipation,  since  it  leaves 
behind  a  considerable  indigestible  residue.  In  general,  therefore, 
sufferers  from  constipation  should  be  given  a  mixed  diet  containing 
a  minimum  amount  of  totally  digestible  foodstuffs  and  a  preponder- 
ance of  those  that  contain  much  indigestible  material.  With  such 
a  regime  we  may  accomplish  much,  but  not  all  we  wish  to.  The  so- 
called  "  physiological  laxatives  "  must  also  be  given.  We  know  a 
number  of  them ;  they  act  either  chemically  or  thermically.  The 
chemical  ones  include  the  organic  acids,  the  mineral  salts,  and 
numerous  sugars  as  well  as  fats.  The  organic  acids  include  lactic, 
butyric,  acetic,  and  probably  also  a  number  of  other  acids  devel- 
oped in  the  body  from  carbohydrates  (formic,  caproic,  caprylic,  pro- 
prionic  acids,  etc.).  As  the  investigations  of  A.  Bokai^  have  shown, 
these  acids  are  important  factors  in  peristaltic  action.  It  is  a  ques- 
tion whether  the  acids  introduced  as  such,  or  those  which  develop 
from  fermentation  in  the  intestines,  are  the  main  causes  of  normal 
peristalsis ;  for  many  reasons  the  latter  variety  should  be  regarded 
as  the  main  cause.  It  is  certain,  however,  that  these  acids  do  excite 
intestinal  peristalsis  very  strongly — more  strongly,  for  example,  than 
do  many  vegetable  cathartics. 

Among  the  foods  which  contain  these  acids  are  buttermilk,  sour 
milk,  kefir,  and  koumyss.  In  the  latter  two  substances  the  carbonic- 
acid  gas  is  also  an  efficient  factor,  for  this  gas  excites  intestinal 
peristalsis. 

We  know  from  animal  experiments  and  observations  upon  man 
that  the  mineral  salts  also  stimulate  peristalsis.  Upon  this  fact  are 
based  our  ideas  of  the  action  of  the  muriated  and  Glauber  salts. 
This  has  taught  us  to  give  patients  suffering  from  habitual  con- 
stipation plentifully  salted  food,  such  as  sardelles,  herring,  caviar, 
smoked  and  boiled  ham,  and  smoked  beef. 

The  sugars  have  long  been  known  as  home  remedies  in  habitual 
constipation.  The  sugars  have  not,  however,  a  common  action  on 
the  organism.  Thus  milk  sugar,  and  probably  also  levulose  and 
dextrose,  have  a  greater  influence  upon  peristalsis  than  has  cane 
sugar.  The  physiological  action  of  the  sugars  may  be  due  to  either 
the  products  of  the  decomposition  of  sugar  in  the  body — i.  e.,  lactic 


^48  DISBASES  OF  THE  INTESTINES 

acid,  butyric  acid,  acetic  acid,  etc. — or  tlie  sugars  may  exert  an  influ- 
ence upon  the  intestinal  mucous  membrane  by  causing  an  active 
transudation  from  it.  The  investigations  of  Strauss  ^  have  shown 
that  after  the  ingestion  of  sugar  considerable  transudation  from  the 
gastric  raucous  membrane  occurs — a  condition  which  I  found  pres- 
ent years  ago  in  experiments  on  the  gastric  digestion  of  sugars. 

The  sugars  have,  therefore,  a  similar  action  to  the  saline  cathar- 
tics (magnesium  sulphate,  sodium  sulphate).  Any  one  of  a  large 
variety  of  saccharin  foodstulfs  can  be  made  use  of  instead  of  sugar 
itself.  Among  these  may  be  mentioned  sweet  fruits,  grapes,  honey, 
sweet  milk  (also  that  sweetened  with  milk  sugar),  condensed  milk, 
sweet  wines  (Tokay,  Marsala,  Sauterne,  pasteurized  graj)e  juice, 
young  wine,  etc.). 

Finally,  the  thermic  methods  should  be  mentioned.  It  is  a  fact 
of  daily  observation  that  cold  appHed  externally  or  internally  stimu- 
lates peristaltic  action.  Many  of  the  laity,  being  cognizant  of  this 
result,  are  accustomed  to  drink  cold  water  on  an  empty  stomach  in 
order  to  stimulate  the  activity  of  the  bowels.  It  is  advisable,  there- 
fore, in  these  cases  to  order  cold  instead  of  warm  or  hot,  and  prefer- 
ably fruit  soups,  cold  tea,  coffee,  sweetened  lemonade,  etc. 

By  means  of  these  substances  we  are  able  to  increase  the  intes- 
tinal activity  at  will.  In  rebellious  cases  of  constipation  one  must 
not,  as  is  so  often  done,  expect  too  much  from  one  particular 
remedy.  Since  these  agents  are  adjuncts  one  to  the  other  they 
must  often  be  combined.  I  am  accustomed  to  name  a  diet  of  this 
kind  a  "  constipation  diet,"  and  I  shall  speak  of  it  more  in  detail  in 
the  second  part  of  this  work.  In  the  selection  of  appropriate  food, 
the  location  of  the  trouble,  its  duration,  and  the  condition  of  the 
patient  have  to  be  considered,  but  the  principles  upon  which  this 
diet  of  constipation  is  based  must  never  be  lost  sight  of,  and  always 
be  applied  in  the  proper  manner. 

As  already  stated  (page  145),  it  is  of  prime  importance  to 
exclude  all  physiologically  constipating  remedies  from  the  diet. 
Thus  I  have  often  seen  patients  for  whom  the  diet  had  been  pre- 
scribed correctly  in  all  respects,  except  that  they  were  allowed  to 
partake  of  one  half  or  even  one  bottle  of  claret  daily — an  absurd 
allowance.  For  similar  reasons,  cocoa,  rice,  farina,  and  foods  pre- 
pared from  flour,  unless  freely  sweetened  with  sugar,  should  be 
forbidden.  I  have  little  doubt  that  a  diet  based  on  principles  as 
above  described  and  varied  for  each  individual  case,  will  result  in 
a  permanent  cure  of  even  rebellious  and  long-standing  cases  of 


THE  DIETETIC  TREATMENT  OP  INTESTINAL  DISEASES    I49 

constipation — a  cure  which  will  satisfy  the  conditions  already 
mentioned  (page  141),  that  even  with  ordinary  diet  the  bowels 
will  move  in  a  normal  manner.  In  those  cases  where  the 
patients  have  been  dosed  with  cathartics  many  years,  only  a  care- 
fully prescribed  diet,  strictly  followed  out  for  years,  may  result 
in  a  cure. 

Besides  the  regulation  of  the  diet,  other  therapeutic  measures 
have  to  be  observed  in  habitual  constipation.  Of  equal  importance 
are  the  regulation  of  the  amount  of  exercise,  stated  hours  for  meals, 
a  regular  and  sufficiently  long  time  for  defecation,  a  stimulation  of 
the  weakness  of  the  intestinal  muscle  by  exercise  of  the  muscles  in 
general,  in  particular  those  of  the  abdominal  wall,  etc.  These  con- 
siderations belong  rather  to  the  special  treatment  of  habitual  consti- 
pation, and  will  be  discussed  in  detail  in  the  second  part  of  this 
work. 

The  choice  of  diet  in  chronic  diarrhoea  depends,  as  has  been 
mentioned  above  (page  144),  upon  the  number  and  consistency  of 
movements  and  the  duration  of  the  affection.  The  most  important 
principles  of  treatment  have  already  been  considered  in  speaking 
of  catarrh  of  the  small  intestine.  The  mechanical,  chemical,  and 
thermal  agents  which  stimulate  peristaltic  action  in  habitual  consti- 
pation have,  on  the  other  hand,  an  unfavourable  influence  on  diar- 
rhoea. In  regard  to  the  first  agent  mentioned,  we  would  therefore 
carefully  avoid  all  coarse,  indigestible,  or  not  easily  digested  sub- 
stances, and  particularly  those  containing  much  cellulose,  such  as 
cabbage,  salad,  pickles,  beets,  and  other  root  vegetables.  Of  the 
chemical  agents,  all  organic  acids  and  sugar  are  to  be  avoided. 
Where  the  food  or  drink  has  to  be  sweetened,  it  is  best  to  use  sac- 
charin— a  substance  which  Gans ',  in  his  investigations  made  in  my 
laboratory  many  years  ago,  showed  was  also  to  a  certain  degree  an 
intestinal  antiseptic.  That  good  fats  even  in  large  quantities  are 
generally  well  home  in  chronic  diarrhoea^  is  worthy  of  mention. 
Experience  has  taught  me  that  even  in  severe  cases  one  can  prevent 
exhaustion  hy  adding  fats  to  the  food.  All  cold  drinks,  ice  water, 
seltzer  water,  and  other  carbonized  beverages  (beer,  champagne, 
etc.),  and  even  cold  water,  should  be  avoided.  Hot  drinks,  on  the 
contrary  (tea,  soups,  and  claret),  have  a  tendency  to  diminish  peri- 
stalsis. As  has  been  mentioned  on  page  144,  milk  is  not,  as  a  rule, 
well  borne,  and  is  apt  to  increase  the  number  of  stools.  Cold  milk 
has  a  very  unfavourable  influence  on  diarrhoea,  while  hot  milk  may 
not  be  harmful.  Sometimes  milk  even  in  large  quantities  is  well 
11 


150  DISEASES  OF  THE  INTESTINES 

borne  when  cognac,  limewater,  powdered  lime,  talcum,  ground  bar- 
ley, rice,  Indian  meal,  or  oatmeal,  etc,  are  added  to  it.  In  a  very 
few  but  convincing  cases  I  have  seen  good  results  from  systematic 
milk  cures,  and  I  believe  that  a  careful  trial  may  be  made  of  them. 
It  is  hardly  necessary  to  add  that  in  these  cases  salts  (table  salt, 
nitre,  and  other  spices)  should  be  forbidden.  If  eggs  (even 
poached)  or  foods  containing  them  are  not  well  borne  they  should 
be  excluded  from  the  diet.  Generally,  at  least  in  the  beginning 
of  the  treatment,  eggs  should  be  sparingly  or  not  at  all  given. 

In  addition,  those  kinds  of  foods  or  drinks  should  be  recom- 
mended which  from  experience^  or  from  whose  composition,  we 
know  tend  to  lessen  peristaltic  activity.  In  this  category  we  may 
mention  the  cereals  which  contain  much  mucin  (farina,  rice,  barley, 
oatmeal,  porridge,  etc.).  These  may  be  ordered  in  the  form  of  soups, 
or,  better,  as  thick,  unsweetened  gruels.*  Other  articles  of  diet 
which  should  be  mentioned  here  are  those  which  are  characterized 
by  containing  more  or  less  tannic  acid.  Among  these  may  be  men- 
tioned "  eichel  cacao,"  "  eichel  coffee,"  infusion  of  nut  leaves  (e.  g., 
butternut),  of  bearberry  leaves  (folia  uva  ursi),  decoctions  and  jel- 
lies of  fresh  huckleberries,  and  a  number  of  red  wines  containing 
much  tannin,  of  which  huckleberry  wine  is  most  useful. 

A  good  old  Bordeaux  wine,  the  Greek  wines  (particularly  Cama- 
rete),  the  Italian  red  wines,  and  Simaruba  wine  may  be  also 
given. 

If  the  patient  will  adhere  strictly  to  this  diet  not  only  during 
the  whole  course  of  treatment,  but  even,  though  not  so  strictly,  for 
many  months  thereafter,  his  intestinal  disturbances  may  be  much 
improved  or  entirely  cured.  In  modern  society,  with  its  dissipation 
and  excesses,  this  plan  of  treatment  will  be  adhered  to  only  by  a 
small  proportion  of  the  patients.  Diet,  however,  is  not  all-suffi- 
cient. It  must  be  remembered  that  other  conditions  (cold,  consti- 
tutional disturbances,  sexual  excesses,  overexertion)  may  have  con- 
siderable influence  upon  the  affection.  This  will  be  treated  of  more 
in  detail  in  Part  II  of  this  book. 

3.   The  Diet  in  Cheonic  Stenosis  and  Obsteuction  of  the 

Intestines 

Chronic  stenosis  occurs  in  different  portions  of  the  intestine, 
either  as  a  benign  (adhesive  peritonitis,  contracting  scars  of  ulcers, 

*  In  these  cases  saccharin  may  be  used  with  much  advantage  instead  of  sugar. 


THE   DIETETIC   TREATMENT   OP  INTESTINAL  DISEASES     151 

benign  tumours)  or  as  a  malignant  process  (carcinoma,  sarcoma). 
No  matter  wliere  the  location  of  the  disease  and  how  great  its 
severity,  the  main  therapeutic  object  must  consist  in  the  removal 
of  the  causal  factor.  Diet  will  naturally  have  some  influence  upon 
this.  Even  if  its  location  be  recognised,  we  are  often  able  to  remove 
the  cause  of  the  obstruction  only  by  operative  means ;  still,  the 
proper  regulation  of  the  diet  may  contribute  much  toward  amelio- 
rating or  removing  subjective  or  objective  symptoms.  In  such  cases 
two  points  have  to  be  considered  before  beginning  the  feeding  :  the 
location  and  the  degree  of  the  obstruction.  The  location  of  the 
disease  may  be  discovered  in  many  if  not  all  of  the  cases.  The 
severity  of  the  symptoms,  the  shape,  consistency  of  the  stools,  the 
visible  or  palpable  peristaltic  restlessness  and  intestinal  rigidity 
(Nothnagel),  the  appearance  of  meteorism,  vomiting,  etc. — all 
these  signs  and  symptoms  indicate,  though  sometimes  falsely,  the 
amount  of  obstruction.  Since  there  are  always  processes  of  putre- 
faction above  the  stenosed  portion  of  the  intestine,  the  direct  bear- 
ing of  the  amount  of  obstruction  upon  the  diet  to  be  prescribed  is 
not  to  be  underestimated.  The  diet  will  differ  according  to  situa- 
tion of  the  obstruction  in  the  large  or  in  the  small  intestine.  The 
chyme  remains  fluid  or  semifluid  until  it  reaches  the  lowest  part 
of  the  ileum,  and  hence  can  pass  through  a  greater  obstruction  here 
than  below  this  point.  Abnormal  processes  of  fermentation  and 
13utref action  are  less  apt  to  occur.  The  diet  should  be  so  arranged, 
therefore,  that  only  fluids  or  foods  prepared  in  liquid  form  are 
taken,  while  solid,  indigestible,  or  not  easily  soluble  matters  are 
to  be  avoided  as  far  as  possible.  It  is  hardly  necessary  to  point  out 
that  food  that  ferments  easily,  or  is  already  in  a  state  of  fermenta- 
tion, should  be  excluded  from  the  diet. 

When  the  obstruction  lies  in  the  large  intestine  the  conditions 
are  far  more  complicated.  In  this  part  of  the  bowel  the  faeces  lose 
most  of  their  water,  and  in  conditions  of  obstruction  this  loss  of 
water  is  further  increased  because  of  the  lack  of  fluid  in  the  sur- 
rounding tissues.  It  matters  not  how  large  an  amount  of  fluid  the 
patient  imbibes,  the  fgeces  are  always  firm  when  they  reach  the 
site  of  obstruction.  One  often  has  to  ask  himself  the  question 
whether  it  might  not  be  advisable  to  order  solid  instead  of  liquid 
food.  Under  a  solid  diet,  however,  there  might  be  danger  of 
increased  fermentation  and  putrefaction  because  of  the  large  quan- 
tities of  easily  putrefactive  material  which  would  reach  the  site  of 
obstruction,  and  furthermore,  on  account  of  the  spasmodic  peristal- 


152  DISEASES  OF  THE  INTESTINES 

sis,  solid  indigestible  substances  might  become  lodged  in  the  stenosed 
portion  of  the  bowel.  Lentils,  peas,  beans,  asparagus,  fruit,  etc.,  in 
short,  those  vegetables  which  contain  much  cellulose,  would  be  most 
apt  to  create  such  a  condition — one  very  similar  to  that  which  occurs 
in  a  typical  manner  in  stenosis  of  the  pylorus.  A  number  of  cases 
have  been  reported  in  which  moderate  errors  of  diet  have  caused  a 
decided  increase  or  an  acute  exacerbation  of  mild  or  quiescent 
symptoms. 

The  diet  in  stenosis  of  the  large  intestines  will  therefore  have 
to  be  based  on  the  following  principles :  1.  It  should  contain  a 
plentiful  amount  of  solid  material.  2.  These  solid  materials  must 
be  free  from  mechanically  irritating  ingredients.  3.  The  diet  must 
contain  laxative  ingredients.  4.  These  must  not  be  excessively  prone 
to  undergo  fermentation.  The  first  two  points  need  no  explana- 
tion ;  some  attention  must,  however,  be  paid  to  the  last  two.  That 
substances  which  tend  to  make  the  stools  less  solid  are  advan- 
tageously added  to  the  diet  has  been  already  clearly  shown  (page 
147).  unfortunately,  however,  some  of  these  substances,  and  among 
them  the  sugars,  form  a  good  substratum  for  the  occurrence  of  fer- 
mentative processes  above  the  site  of  the  obstruction ;  hence  they 
must  be  avoided.  Experience  has  taught  me  that  organic  fatty  acids 
and  the  acids  of  fruits  are  generally  well  borne.  The  same  is  true 
of  salts,  which  probably  diminish  and  certainly  do  not  increase  fer- 
mentation in  the  intestinal  canal.  A  plan  of  diet  based  on  such 
principles  may  be  given  in  short  resume  in  the  following :  Mixed 
food — meat,  fish,  vegetables,  etc. — should  be  prepared  in  puree 
form;  well-salted  and  pickled  meat  or  fish  are  especially  recom- 
mended. Fat  may  be  given  in  moderate  quantities.  Sweet  milk  is 
not  well  borne,  but  buttermilk,  thickened  milk,  kefir  (free  from 
carbonic  acid  and  two  days  old),  koumyss  (free  from  carbonic  acid) 
are  permissible.  No,  or  only  small  quantities  of,  sweet  stewed 
fruit,  in  which  saccharin  may  be  used  instead  of  sugar,  should  be 
allowed.  A  diet  suitable  for  each  individual  case  may  be  con- 
structed on  these  principles.  It  is  of  prime  importance  to  counter- 
act the  tendency  to  severe  grades  of  constipation  ;  and  if,  as  is  often 
the  case,  the  regulation  of  the  diet  will  not  sufiice,  one  must  occa- 
sionally order  mild  vegetable  laxatives.  It  would  be  a  palpable 
error  to  order  a  constipating  diet  for — or,  what  is  still  worse,  to  give 
opiates  to- — a  patient  who  has  partial  intestinal  obstruction.  An 
exception  to  this  statement  is  furnished  by  those  cases  of  spas- 
modic tetanic  intestinal  peristalsis,  in  which  opium  not  only  quiets 


THE  DIETETIC   TREATMENT   OF   INTESTINAL  DISEASES    153 

tlie  contractions,  but  even  acts  as  a  laxative.     This  subject  will, 
however,  be  treated  of  in  another  place. 

The  diet  to  be  used  in  complete  intestinal  obstruction  differs 
essentially  from  that  in  partial  obstruction.  In  complete  obstruction 
the  diet  must  be  very  limited.  Obviously  this  is  of  paramount 
importance  when  the  obstruction  is  in  the  small  intestines,  for  in 
these  cases  the  entry  of  food  into  the  stomach  or  intestines  causes 
immediate  vomiting.  When  the  obstruction  is  in  the  large  intes- 
tines (invagination,  volvulus,  foreign  bodies,  fsecal  impaction)  this  is 
also,  though  in  a  less  degree,  true.  Only  small  quantities  of  very 
easily  digestible  foods,  preferably  fluids,  should  be  given  at  long 
intervals,  and,  when  possible,  nourishment  by  some  other  path 
should  be  at  once  begun  (nutrient  enemata,  subcutaneous  saline 
infusion,  salt-water  enemata).  Weakness,  with  cardiac  exhaustion, 
is  to  be  greatly  feared,  since  it  will  prevent  the  one  therapeutic 
curative  method  in  the  disease,  namely,  operation. 

When  the  obstruction  is  in  the  small  intestine,  or  in  the  upper 
part  of  the  large  intestine,  the  patient  should  be  given  nutrient 
enemata.  If  in  the  lowermost  portion  of  the  large  intestine  or  the 
rectum,  the  best  one  can  do  is  to  attempt  to  prevent  threatening 
collapse  by  injections  of  salt  or  glucose  under  the  skin.  In  most 
of  the  cases  the  result  is  unfavourable  unless  surgical  aid  is  early 
called  in. 

4.    The  Diet  in  Typhlitis  and  Appendicitis 

By  appendicitis  we  mean  those  inflammations  which  start  from 
the  appendix  vermiformis  and  either  remain  localized  or  extend  to 
the  peritoneum  or  retroperitoneal  cellular  tissue,  or  through  perfo- 
ration attack  a  part  or  the  whole  of  the  peritoneal  cavity.  A  pri- 
mary typhlitis  caused  by  fsecal  impaction  or  foreign  bodies,  and 
often  followed  by  perityphlitis  with  its  symptoms,  does  occur. 
With  this  short  statement  of  my  position  on  an  affection  which  has 
been  the  cause  of  much  clinical  difference  of  opinion,  I  shall  close 
this  subject  and  turn  to  the  dietetic  treatment  of  the  condition, 
reserving  the  details  for  discussion  in  another  place. 

It  is  exceedingly  difficult  to  lay  down  any  general  rules  of  diet, 
because  in  these  affections  the  food  must  vary  with  the  character, 
severity,  and  course  of  the  disease,  as  well  as  with  the  varying  com- 
plications and  relapses.  In  stercoral  typhlitis  the  question  is  easy ; 
in  appendicitis  it  is  more  difficult.  For  simplicity,  I  think  it  best 
to  adhere  to  the  classification  proposed  by  Sonnenburg,  into  the 


154:  DISEASES  OF  THE  INTESTINES 

catarrhal,  the  perforative,  and  the  gangrenous  forms  of  appendi- 
citis. 

In  typhlitis  due  to  fsecal  impaction  the  diet  must  be  so  arranged 
as  to  aid  in  the  softening  and  discharge  of  the  faeces.  The  use  of 
laxatives  (castor  oil)  or  of  enemata  can  be  advantageously  combined 
with  a  suitable  diet. 

In  most  cases  catarrhal  appendicitis  gets  well  of  its  own  accord, 
and  the  treatment  must  be  so  directed  as  neither  to  irritate  the 
intestines  mechanically  nor  to  increase  peristalsis.  This  is  best 
accomplished  by  means  of  a  fluid  diet,  continued  until  the  rise  of 
temperature,  the  exudate,  and  the  sensitiveness  to  pressure  in  the 
ileo-csecal  region  have  disappeared.  Judging  from  my  experience, 
I  believe  that  Sahli^,  Quincke^,  and  Penzoldt^^  are  too  extreme 
when  they  recommend  that  for  one  or  more  days  all  food  should 
be  at  once  withdrawn. 

After  the  acute  inflammatory  symptoms  have  disappeared,  we 
may  for  the  next  week  allow  the  patient,  in  addition  to  fluids,  to 
partake  of  gruels  (rice,  barley  gruels,  vegetables  in  puree  form,  etc.). 
After  another  week  meat,  beginning  with  the  tender  varieties,  may 
be  added,  together  with  foods  made  of  flour  and  various  stewed  and 
preserved  fruits.  After  four  weeks  have  elapsed  the  patient  may 
return  to  his  normal  diet,  which  should  be  so  arranged  as  to  coun- 
teract the  tendency  to  constipation  which  is  always  present  in  these 
cases. 

In  the  second  variety,  the  suppurative  form  of  appendicitis,  the 
danger  to  life  is  much  greater,  and  the  main  question  is  when 
to  interfere  surgically.  Diet  is  of  secondary  importance.  Even 
in  these  patients  I  do  not  believe  that  an  absolute  withdrawal  of 
food  is  advisable,  because,  on  account  of  the  high  fever,  the  patients 
generally  suffer  from  severe  thirst.  Penzoldt  permits  his  patients 
to  drink  water,  and  hence  I  do  not  see  why  they  may  not  also  take 
small  quantities  of  tea,  milk,  wine,  and  gruels.  It  seems  to  me  that 
the  fear  of  a  "dangerous  stimulation"  of  peristalsis  is  exaggerated, 
all  the  more  as  the  opium  treatment  is  more  thoroughly  carried 
out.*  This  does  not  mean,  of  course,  that  one  should  not  withdraw 
all  feeding  by  the  mouth  where  there  is  severe  vomiting  or  symp- 
toms of  intestinal  obstruction,  and  use  in  its  stead  frequently 
repeated  nutrient  enemata.     In  general,  however,  in  acute  or  sup- 

*  [Within  recent  years,  here  in  the  United  States,  routine  opium  treatment — for- 
merly so  popular — has  been  almost  entirely  abandoned,  even  in  those  cases  treated 
without  operation. — Tb.] 


THE  DIETETIC  TREATMENT   OF   INTESTINAL   DISEASES     155 

purative  stages  of  the  affection,  rectal  alimentation  must  be  desisted 
from,  if  possible,  since  it  necessitates  moving  the  patient  about  and 
naturally  disturbs  the  inflamed  intestine.  If  the  critical  stage  of 
the  disease  is  passed,  or  if  an  operation  has  freed  the  patient  from 
danger,  the  diet  must  be  arranged  according  to  the  principles  above 
mentioned. 

The  same  general  principles  apply  also  to  the  gangrenous  variety 
of  the  disease,  but  the  diet  must  be  still  more  carefully  managed. 
The  bowels  should  be  regulated,  and  by  this  means  the  occurrence 
of  relapses  prevented.  Only  in  very  resistant  cases  should  laxatives 
be  made  use  of,  and  one  should  endeavour  to  regulate  the  bowels  by 
means  of  the  appropriate  diet  for  constipation  which  has  already 
been  described. 

As  the  rarer  forms  of  tubercular  and  actinomycotic  appendicitis 
do  not  differ  essentially  from  the  forms  above  described,  it  will  be 
unnecessary  to  detail  the  principles  of  feeding  in  these  cases. 

5.   The  Diet  in  Intestinal  I^eukoses 

The  practical  importance  of  the  dietetic  treatment  of  intestinal 
neuroses  is  that  by  its  means  we  may  improve  the  general  condition 
of  the  patient  or  remove  prominent  symptoms  of  the  affection  (con- 
stipation, diarrhoea,  pain,  flatulence,  etc.).  If  the  diagnosis  is  abso- 
lutely certain,  it  is  questionable  whether  any  special  regiine  is  neces- 
sary at  all.  Many  errors  are  made  in  this  direction.  I  have  seen, 
for  example,  a  strict  diet  cause  or  increase  constipation,  tympanites, 
and  colic,  which  symptoms  had  presented  almost  a  typical  picture 
of  nervous  dyspepsia.  Such  patients  tell  us  that  they  can  not  even 
partake  of  soup  without  being  troubled  with  belching  or  with  severe 
tympanites  and  abdominal  pain.  Often  the  patient  will  be  imme- 
diately cured  by  partaking  of  a  full  diet.  I  would  therefore 
emphatically  warn  physicians  against  restricting  the  diet  too  quickly 
when  they  have  patients  who  complain  of  intestinal  symptoms  with- 
out discoverable  physical  signs.  In  some  cases,  as  in  the  so-called 
nervous  diarrhoea,  this  is  to  some  extent  necessary.  But  even  in 
these  cases  one  should  in  some  degree  be  guided  by  the  sensations 
of  the  patient,  and  should  not  order  all  possible  sorts  of  restrictions 
at  once.  The  patients  may  make  strange  assertions  which  contra- 
dict all  the  acknowledged  laws  of  physiology  and  pathology,  but 
these  statements  must  not  be  absolutely  ignored.* 

*  Thus,  I  have  a  patient  in  whom  even  the  best  kind  of  claret  always  causes 
diarrhoea,  although  Moselle  wine  promptly  counteracts  the  effect  of  the  red  wine. 


156  DISEASES  OP  THE  INTESTINES 

This  class  of  patients  is  best  treated  in  a  sanitarium,  where 
observation  will  soon  show  the  appropriate  diet  for  the  indi- 
vidual case. 

The  treatment  of  nervous  flatulence — a  condition  whose  treat- 
ment, in  the  experience  of  every  busy  practitioner,  gives  very  unsat- 
isfactory therapeutic  results — must  be  considered  in  this  place. 
The  attempt  to  determine  the  cause  of  the  flatulence  meets  with 
many  difiiculties.  In  more  than  one  case,  even  after  long  obser- 
vation, I  have  been  in  doubt  as  to  the  nature  of  the  process,  and 
more  especially  whether  or  not  there  was  abnormal  fermentation  in 
the  intestines.  N^ot  only  do  the  patients  not  improve  under  strict 
dietetic  treatment,  but  they  often  become  distinctly  worse.  Tym- 
panites and  constipation,  when  they  occur  together,  may  be  regu- 
lated by  an  appropriate  but  not  a  bland  diet ;  diarrhoea  may,  how- 
ever, be  accompanied  by  tympanites,  and  a  constipating  diet  then 
becomes  necessary.  Above  all,  fluid  food  should  be  avoided,  as 
such  a  diet  will  make  the  patient's  condition  almost  unbearable. 
Yery  many  practitioners  are  afraid  to  give  so-called  gas-forming 
remedies,  but  these  are  often  indicated.  In  the  same  manner  that 
the  sense  of  pressure  in  the  epigastrium  must  be  relieved  by  the 
taking  of  bicarbonate  of  soda,  so  we  can  often,  by  means  of  a  diet 
rich  in  gas-forming  foods,  make  it  easier  for  the  patient  to  expel 
gas  from  his  bowel.  Many  patients  of  mine  who  are  very  sceptical 
on  this  point  have,  to  their  great  surprise,  been  benefitted  by  this 
kind  of  a  diet.  But  even  in  these  cases  individual  predisposition 
must  be  taken  into  consideration. 

6.  Diet  in  Diseases  of  the  Rectum 

I^ot  all  affections  of  the  rectum  require  a  special  regulation  of 
the  diet.  Thus,  no  special  diet  is  necessary  in  fistulse,  ulcers,  or 
foreign  bodies  in  the  rectum.  This  statement  does  not  mean  that 
in  none  of  the  affections  of  the  rectum — especially  the  surgical  dis- 
eases— is  a  regulation  of  the  diet  necessary.  In  some  affections  of 
the  rectum — stenosis  and  strictures,  hemorrhoids,  and  fissures — a 
systematic  regulation  of  the  diet  is  indicated.  As  regards  the  first 
of  these  affections,  the  diet  to  be  ordered  is  the  same  as  that  for 
obstructions  of  the  intestines  situated  higher  up  in  the  alimentary 
canal. 

Special  treatment  is  necessary  for  hemorrhoids  because  of  the 
tendency  to  constipation,  alternating  perhaps  with  diarrhoea,  and  on 
account  of  the  bleeding  which  may  occur.     The  bowels  should  be 


THE  DIETETIC  TREATMENT   OP  INTESTINAL  DISEASES    157 

regulated,  and  for  this  purpose  tlie  "  constipation  diet "  will  usu- 
ally suffice.  Where  both  patient  and  physician  are  impatient,  mild 
laxatives  may  be  used. 

Where  the  tendency  to  profuse  hemorrhages  exists,  substances 
whicb  increase  the  discharge  of  fluids  from  the  intestines — i.  e., 
acids,  alcohol,  spices — should,  if  conditions  permit,  be  excluded  from 
the  diet. 

The  diet  in  fissures  of  tlie  rectum  and  proctitis  should  be  so 
arranged  that  the  movements  are  retarded  as  mucb  as  possible ;  if 
necessary,  opium  may  be  used.  Generally  this  treatment  is  very 
satisfactory  to  the  patients  because  every  movement  is  apt  to  be 
followed  by  severe  pain.  I  keep  these  cases  on  a  soup  diet  from 
eight  to  ten  days.  When  the  fissure  bas  healed  and  there  is  no  more 
pain  during  or  after  movements,  a  dose  of  castor  oil  should  be  given. 
Gradually  the  patient  may  be  permitted  to  return  to  bis  usual  diet. 
In  proctitis  the  diet  should  be  managed  in  such  a  manner  that  all 
irritating  substances  are  excluded,  and  that  the  movements  are  soft 
and  easily  passed.  When  the  movements  are  very  painful  the  patient 
should  be  placed  on  a  bland  diet,  and,  until  the  inflammation  has  dis- 
appeared, the  intestinal  peristalsis  should  be  diminished  by  means  of 
opiates.  Similar  treatment  is  also  called  for  in  periproctitis,  and  is 
rendered  more  easy  of  accomplishment  because  the  appetite  of  the 
patient  is  diminished  through  the  severe  pain  and  the  high  fever 
characteristic  of  the  affection.  In  other  cases,  a  careful  empty- 
ing of  the  colon  (by  means  of  injections  and  intestinal  lavage)  is 
indicated. 

LITERATURE 

1.  Rubner.     Zeitschr.  f.  Biologie,  Bd.  xv,  S.  115. 

2.  Fr.  Müller.     Zeitschr.  f.  klin.  Medicin,  Bd.  xii. 

3.  Hirschler.     Zeitschr.  f.  physiol.  Chemie,  Bd.  x,  S.  306. 

4.  Ortweiler.     Mittheilungen    aus   d.   medicin.    Klinik   in  Würzburg,    1886, 

Bd.  ii. 

5.  Bokai.     Arch.  f.  experira.  Pathol,  u.  Pharmakol.,  Bd.  xxiii. 

6.  Strauss.     Zeitschr.  f.  klin.  Medicin,  Bd.  xxix,  1896,  S.  221. 

7.  Gans.     Berliner  klin.  Wochenschr.,  1889,  No.  13. 

8.  Sahli.     Verhandl.  des  Congresses  f.  innere  Medicin,  1895. 

9.  Quincke.     Ibid. 

10.  Penzoldt.     Handbuch  d.  spec.  Therapie  innerer  Krankheiten,  Bd.  iv,  S.  724. 


CHAPTER  IX 

THE  HYDRO  THERAPEUTICS   OF  INTESTINAL  DISEASES 

In  tlie  treatment  of  affections  of  the  intestines,  hydrotherapy 
plays  almost  as  important  a  part  as  in  that  of  the  stomach.  It  is, 
however,  very  difficult  to  give  a  good  account  of  the  action  of  hydro- 
therapeutic  measures,  be  the  water  taken  internally  or  as  baths,  or 
both  together,  or  to  determine  exactly  what  effects  climatic  influ- 
ences have  upon  the  patient.  The  number  of  factors  that  have  to 
be  taken  into  account  is  so  large  that  in  the  greater  number  of  cases 
it  is  hard  to  say  what  part  of  the  results  obtained  is  due  to  rest  and 
exercise,  to  diet,  to  the  change  in  surroundings,  or  to  the  treatment  of 
the  physicians  at  the  watering  place  visited  by  the  patient.  We  are 
often  in  the  position  of  the  physician  who  has  given  a  prescription 
containing  four  or  five  drugs ;  the  patient  is  improved,  but  the  physi- 
sician  is  unable  to  say  to  which  one  of  the  drugs  the  result  was  due. 

The  employment  of  mineral  waters  is  to  a  certain  extent  empiri- 
cal, for  we  really  have  little  positive  knowledge  concerning  the  action 
of  these  waters  on  the  healthy  or  diseased  intestines  that  we  could 
use  as  a  basis  for  a  systematic  treatment.  Every  busy  practitioner, 
therefore,  is  accustomed  to  formulate  therapeutic  principles  for  him- 
self according  to  his  experience  with  these  agents.  As  in  my  Dis- 
eases of  the  Stomach,  I  shall  also  here  give  an  account  of  the  impres- 
sions which  I  have  gained  from  an  experience  vrith  a  large  number 
of  carefully  observed  cases. 

Eor  simplicity,  hydrotherapeutic  measures  may  be  divided  into 
the  drinking  of  waters,  hydrotherapeutic  baths,  seashore,  and  moun- 
tain-air cures.  The  hydrotherapeutic  procedures  proper  will  be 
considered  in  the  Special  Part  of  this  book. 

1.  The  DrmTcing  of  Waters. — The  influence  of  a  course  of  waters 
is  based  upon  their  action  upon  the  intestine.  They  may  stimulate 
or  diminish  peristalsis;  they  may,  so  to  say,  wash  out  the  entire 
alimentary  canal  and  remove  mucus,  bacteria,  and  various  toxic 
products  from  its  interior.  The  Avaters  may  have  only  an  indirect 
action  upon  the  intestines ;  for  example,  in  those  cases  where  an 
improvement  of  an  affection  of  other  organs  (gastric,  hepatic,  or 
158 


THE  HYDßOTHBRAPEUTICS   OF  INTESTINAL   DISEASES     I59 

cardiac  disease)  is  followed  by  an  improved  condition  of  the  intes- 
tinal functions. 

We  will  limit  ourselves  to  a  consideration  of  the  direct  action  of 
waters  upon  intestinal  diseases,  and  shall  first  give  an  account  of  the 
mineral  waters  which  increase  peristaltic  action.     These  are : 

(«)  Alkaline  carbonated  waters  (main  constituents,  bicarbonate 
of  soda  and  carbonic  acid). 

(5)  Alkaline  mnriated-carbonated  waters  (main  constituents,  so- 
dium carbonate  and  chlorid,  carbonic-acid  gas). 

(0)  Sodium  sulphate  waters  (main  constituent,  sodium  sulphate). 

{cT)  Muriated  waters  (main  constituent,  sodium  chlorid). 

{e)  Bitter  waters  (main  constituents,  sodium  and  magnesiuai 
sulphate). 

As  regards  the  first  group,  they  have  only  a  very  slight  effect  in 
increasing  the  activity  of  the  intestines.  Owing  to  the  sodium  bicar- 
bonate and  carbonic  acid  contained  in  them,  they  may  act  as  laxa- 
tives when  given  in  very  large  doses.  Their  use  would  be  limited 
to  very  mild  cases  of  constipation,  and  to  those  diseases  in  which  a 
very  slight  laxative  action  is  desired  in  addition  to  the  general  tonic 
effect  of  a  mineral  water.  It  need  hardly  be  mentioned  that  the 
cold  waters  have  more  effect  than  the  warm  waters. 

Cold  alkalme  carbonated  waters  may  be  arranged,  according  to 
their  percentage  of  bicarbonate  of  soda,  into  *  Yals,  Bilin,  Fachingen, 
Fellathalquelle,  Preblau,  Salzbrunn,  Geilnau,  and  Giesshiibl.  Ther- 
mal alkaline  carbonated  waters  are  Yichy  and  JSTeuenahr. 

[In  the  United  States  we  have  the  following  springs  of  this 
class  (arranged  in  the  order  of  their  percentage  of  bicarbonate  of 
soda)  :  Cold  springs  :  The  California  Seltzers,  Azula  Springs  (Cali- 
fornia), Bladon  Springs  (Alabama),  Adam's  Springs  (California), 
and  Waukesha  (Wisconsin).  Thermal  springs  :  Ukiah  Yichy  (Cali- 
fornia), Howard  (Excelsior  Spring)  (California);  and,  as  an  example 
of  the  hot  alkaline  carbonated,  we  have  Skagg's  Hot  Springs  in 
California  (temperature  =  120°  to  140°  F.).] 

The  second  group  of  waters,  the  alkahne  muriated,  have  a  similar 
action  to  that  of  the  first  group,  except  that  the  high  percentage 
of  sodium  chlorid  which  some  of  them  contain  may  make  them  par- 
ticularly useful  in  the  treatment  of  constipation.      Of  course  the 

*  The  detailed  account  of  these  mineral  waters  may  be  found  in  my  work  on 
the  Diagnosis  and  Treatment  of  Diseases  of  the  Stomach  (Part  I,  p.  282  et  seq., 
fourth  edition). 


160  DISEASES   OP  THE  INTESTINES 

temperature  of  the  water  lias  its  due  influence.  Among  the  cold 
muriated  springs  I  may  mention  Sczawnicza  (Magdalen  Spring, 
4.61  grams  of  ISTaCl  per  litre),  Luhatschowitz  (Yincenz  Spring,  3 
grams  ISTaCl  per  litre),  Gleichenberg  (Constantin  Spring,  1.85  grams 
^aCl  per  litre),  Selters  (2.3  grams  J^aCl  per  litre),  Tönnistein  (1.4 
grams  per  litre).  Among  thermal  chlorid  waters  may  be  men- 
tioned Ems  (Fürsten  Springs,  1  gram  JSTaCl  per  litre). 

[The  most  celebrated  springs  of  this  group  in  the  United  States 
are  those  of  Saratoga  in  IsTew  York.  In  all,  there  are  between 
twenty  and  thirty  springs  at  this  famous  watering  place.  The  amount 
of  sodium  chlorid  found  in  them  ranges  from  1.86  grams  (Flat 
Rock  Spring)  to  12.04  grams  (Champion  Spouting  Spring)  per 
litre,*  Between  these  two  extremes  there  exists  a  most  varying 
percentage.  Other  cold  alkaline  muriated-carbonated  waters  are 
those  of  the  Tolenas  Springs,  California  (3.3  grams  per  htre) ;  the 
Pacific  Congress,  California  (2  grams)  ;  the  Dixie  Springs,  Tennessee 
(1.9  grams) ;  the  St.  Clair  (Salutaris)  Springs,  Michigan,  the  Litton 
Seltzer,  California  (each  containing  about  1.4  grams  to  the  litre) ; 
the  ^tna  Soda  Springs,  California  (0.5  gram  to  the  litre) ;  Mani- 
tou,  Colorado  (0.41  gram) ;  the  Medical  Lake,  Washington  State, 
and  the  Plymouth  Eock,  Michigan  (each  with  about  0.26  gram) ; 
and  the  Cresson  Magnesia  Springs,  Pennsylvania,  which  contains 
but  0.021  gram  to  the  litre.  As  examples  of  thermal  and  hot 
springs  of  the  group  under  discussion  we  have  the  Las  Yegas  Hot 
Springs  of  Kew  Mexico  (temperature  from  110°  to  140°  F.),  whose 
largest  spring  (ßo.  6)  contains  0.26  gram  of  J^aCl  to  the  litre ; 
the  Ojo  Caliente  Hot  Springs  (temperature  90°  to  122°  F.),  fifteen 
in  number,  and  containing  0.38  gram  to  the  litre ;  the  Aguas  Cali- 
ente (Coahuila  Yalley,  California),  which  contain  0.53  gram  to  the 
litre,  and  whose  temperature  varies  from  58°  to  142°  F.  Finally, 
there  is  the  Fountain  Geyser  of  the  Yellowstone  K^ational  Park 
(temperature  1Y9.6°  F.),  whose  water  is  estimated  to  contain  0.54 
gram  of  I^aCl  to  the  litre.f  ] 

The  third  group  of  waters  contains  a  greater  or  less  quantity 
of  sodium  sulphate  and  a  small  percentage  of  sodium  bicarbonate 
and  chlorid,  and  carbonic  acid.     Gold  water  springs  are  Marienbad, 

[*  These  figures  and  most  of  those  herein  stated  are  taken  from  the  tables  of 
analyses  given  in  Crook's  Mineral  Waters  of  the  United  States,  etc.,  the  latest  and 
undoubtedly  the  best  work  on  the  subject. — Tr.] 

[f  The  waters  of  these  hot  springs  are  employed  mostly  for  bathing  pur- 
poses.— Te.] 


THE  HYDROTHERAPEÜTICS   OF  INTESTINAL  DISEASES     161 

Tarasp,  Elster  (Salt  Spring),  Rohitsch,  Franzensbad  (Salt  Spring). 
Thermal  springs  are  Carlsbad  and  Bertrich. 

The  cold  sodium  sulphate  waters  have  a  greater  cathartic  action 
than  the  warm  ones.  Carlsbad  is  vaunted  for  its  special  good  effects 
on  chronic  catarrhs  of  the  small  and  large  intestines.  Marienbad 
and  the  Salt  Springs  of  Franzensbad  and  Elster  are  particularly  rec- 
ommended for  hemorrhoidal  affections  and  abdominal  plethora  with 
constipation. 

[Very  few  of  the  cold  springs  of  the  United  States  of  which  we 
have  a  trustworthy  analysis  contain  a  preponderance  of  sodium  sul- 
phate over  the  other  mineral  ingredients.  Such  are  the  Lineville 
Mineral  Springs  of  Iowa,  which  contain  3.1  grams  of  sodium  sul- 
phate to  the  litre ;  the  Rocky  Mountain  Springs  of  Colorado,  with 
1.8  grams  of  sodium  sulphate  to  the  litre ;  the  Aqua  de  Yida  of 
California,  the  Lower  Spring  with  0.25  gram,  and  the  Upper  with 
0.3  gram  to  the  litre.  The  Upper  Spring  also  contains  magnesium 
sulphate.  Porter  Springs,  Colorado,  contain  0.47  gram  of  sodium 
sulphate  to  the  litre. 

The  thermal  and  hot  springs  are  more  numerous.  As  examples 
we  have  the  Arrow  Head,  the  San  Bernardino,  and  the  Great  Pa- 
raiso  Hot  Soda  Spring  of  California ;  the  Pagosa  and  the  Middle 
Park  Hot  Springs  of  Colorado ;  the  Ferris  of  Montana ;  and  Wal- 
ley's  Hot  Springs  and  Gibson's  Mineral  Well  of  Texas.  The  sodium 
sulphate  in  these  waters  varies  from  0.021  gram  (Walley's)  to  4.4: 
grams  (Gibson's)  to  the  litre.] 

The  m,uriated  waters  contain  more  or  less  sodium  chlorid  and  a 
considerable  quantity  of  carbonic  acid.  Cold  springs  are  ISTauheim 
(Kurbrunnen),  Neuhaus  (Bonifacius  Spring),  Homburg  (Elizabeth 
Spring),  Mergentheim,  Kissingen,  Soden.  Thermal  springs  are 
Wiesbaden  (Kochbrunnen)  and  Bourbon  les  Bains. 

[Many  cold  waters  of  this  group  are  found  in  the  United  States ; 
some  have  too  high  a  percentage  of  sodium  chlorid  to  render  them 
suitable  for  anything  but  bathing.  Such  are  the  l^eptune  Spring 
(Glen  Springs,  ISTew  York),  which  contains  109.18  grams,  and 
Clark's  Red  Cross  Mineral  Well,  containing  223.81  grams  per  litre. 
The  best  known  of  the  drinking  waters  are  those  of  Ballston  Spa 
in  Kew  York  (United  States  =  Y.29  grams  sodium  chlorid  and 
Sans  Souci  =  1.46  grams  to  the  litre) ;  Sheboygan  Mineral  Well  in 
Michigan,  with  5.24  grams ;  and  Glen  Springs  in  I^ew  York  (Salu- 
bria  =  3.37  grams ;  Deer  Lick  =  1.99  grams).  Less  generally 
known,  but  enjoying  an  excellent  local  reputation,  are  the  Louis- 


1(52  DISEASES  OP  THE  INTESTINES 

yille  Artesian  Well  (Kentucky),  the  Lodi  Artesian  Well  (Indiana), 
the  Sweet  Springs  of  Missouri,  the  Spring  Lake  Well  of  Michigan, 
the  Wasatka  Mineral  Springs  of  Utah,  and  the  Coronado  Springs 
of  California.  A  number  of  otherwise  excellent  muriated  waters 
contain  large  amounts  of  sulphuretted  hydrogen,  so  that,  strictly 
speaking,  they  do  not  belong  in  this  class.  These  include  the 
Tipper  and  Lower  Blue  Lick  and  the  Olympian  Springs  of  Ken- 
tucky, the  Akesion  (Sweet  Springs)  of  Missouri,  the  Cincinnati 
Sulpho-saline  Spring,  etc. 

There  are  fewer  hot  and  apparently  no  thermal  muriated 
springs.  The  Utah  Hot  Springs  (131°  to  140°  F.),  the  Yampa 
(Glenwood  Springs)  (Colorado),  and  the  Koyal  George  Hot  Springs 
(Colorado),  used  for  bathing  purposes,  are  to  be  classed  with  this 
group  of  waters.] 

The  muriated  waters  improve  the  appetite,  and  in  large  doses 
increase  intestinal  peristalsis  and  thus  clear  the  organism  of  excre- 
mentitious  material. 

The  main  action  of  the  bitter  waters  is  cathartic,  and  hence  they 
may  be  used  to  clear  the  blood  and  general  system  of  useless  sub- 
stances. We  may  mention  Franz  Joseph  Spring  in  Buda-Pesth  (24 
grams  of  magnesium  sulphate  and  23  of  sodium  sulphate  per  litre), 
Hunyadi  Janos  in  Buda  Pesth  (16  grams  of  magnesium  sulphate 
and  15  of  sodium  sulphate  per  litre),  Piilna  in  Bohemia  (12  grams 
of  magnesium  sulphate  and  16  of  sodium  sulphate  per  litre),  Fried- 
richshall (5  grams  of  magnesium  sulphate  and  6  of  sodium  sulphate 
per  litre),  Apenta,  etc. 

[There  are  between  twenty  and  thirty  cold  and  thermal  bitter- 
water  springs  in  the  United  States.  Although  none  have  as  high  a 
percentage  of  magnesium  or  sodium  sulphate  as  the  above-mentioned 
European  waters,  still  many  of  them  are  excellent  cathartic  waters. 
At  the  head  of  the  cold  springs  stand  the  B.  B.  Mineral  Springs  of 
Missouri,  which  contain  11.5  grams  of  magnesium  sulphate  and  1.04 
of  sodium  sulphate  per  litre ;  the  Estill  (Purgative)  Springs,  4.5 
grams  of  magnesium  and  1  of  sodium  sulphate ;  the  Epsom  Spring 
(Crab  Orchard,  Kentucky),  3.5  grams  of  magnesiuni  and  1  of 
sodium  sulphate  per  litre ;  the  Harrodsburg  Springs,  Kentucky 
(Saloon  Spring  =  3.8  grams  and  Grenville  =  2.2  grams  magnesium 
sulphate  per  litre) ;  Sowder's  Spring  (Crab  Orchard)  has  3  grams 
of  magnesium  and  0.4  of  sodium  sulphate ;  Foley's  Spring,  3.4 
grams  of  magnesium  and  1  of  sodium  sulphate  ;  Mono  Lake  (Cali- 
fornia) contains  2.1  grams  of  magnesium  and  0.3  of  sodium  sul- 


THE  HYDROTHERAPEUTICS   OF   INTESTINAL   DISEASES      163 

pliate  ;  the  American  Carlsbad  Springs*  (Illinois),  1.8  grains  of 
magnesium  and  0.1  of  sodium  sulphate,  and  the  Gypsum  Springs 
of  Arizona  have  l.T  grams  of  magnesium  with  0.5  of  sodium  sul- 
phate. The  remaining  springs  contain  magnesium  sulphate  in 
amounts  varying  from  0.02  gram  to  0.9  gram  to  the  litre.  Men- 
tioned according  to  their  percentage  of  magnesium  sulphate,  they 
are  the  Alleghany  Springs  of  Virginia,  the  Mineral  Park  Bitter 
Spring  (Arizona),  the  Greenbrier  (West  Virginia),  the  Bedford 
(Magnesia  and  Bowling  Alley)  Springs  (Pennsylvania),  Seigleris 
(Magnesia)  Spring  (California),  and  the  Mountvale  Springs  (Ten- 
nessee). Others  charged,  however,  with  sulphuretted  hydrogen 
are  the  Avon  Sulphur  and  Sharon  Springs  f  of  'New  York,  the  Salt 
Sulphur  Springs  of  West  Virginia,  the  French  Lick  Springs  (Pros- 
erpine and  Pluto)  of  Indiana,  and  the  Indian  Springs  of  Georgia. 

As  examples  of  thermal  and  hot  bitter  waters  we  cite  the  Soda 
(drinking)  Spring  (Virginia  Hot  Springs),  temperature  =  74:°  F. ; 
the  Idaho  Hot  Spring  (Colorado),  temperature  =  85°  to  115°  F. ; 
the  numerous  Catoosa  Springs  of  Georgia,  temperature  =  212°  F.] 

There  are  some  mineral  waters  which  diminish  peristalsis.  All 
the  waters  mentioned  above,  except  the  bitter  waters,  when  they  are 
taken  warm  and  in  small  doses,  have  this  action.  Especial  mention 
nmst  be  made  of  Carlsbad  Sprudel  water,  which  has  a  great  reputa- 
tion in  chronic  diarrhoea.  In  addition,  the  waters  which  contain 
lime  and  iron  must  be  considered  in  this  connection. 

Of  the  lime  waters,  particularly  those  which  contain  calcium 
carbonate,  Germany  has  the  following  varieties :  Wildungen  (König's 
Spring),  Driburg  (Herster  Spring),  Lippspringe  (Arminius  Spring), 
Eappoldsweiler  (Carola  Spring),  Marienbad  (Eudolf's  Spring),  Co- 
burg  (Mariannen  Spring) ;  the  last-named  water  is  generally  used  for 
exportation.    The  table  below  gives  the  composition  of  these  waters : 


Wildungen  (König's  Spring,  temperature  10°  C).  •  • 
Driburg  (Herster  Spring,  temperature  10.6°  C.)  . .  • 
Rappoldsweiler  (Carola  Spring,  temperature  18°  C.) 
Lippspringe  (Arminius  Spring,  temperature  21.2  G.) 
Coburg  (Mariannen  Spring) 


Carbonate  of  lime 

Free  CO,. 

and  carbonate  of 

Cubic 

magnesium  in  litres. 

Centimetres. 

2.23 

1.323 

1.51 

1,043 

0.77 

0.61 

646 

0.3463 

343 

[*  The  name  "  Carlsbad  "  is  inappropriate,  for  the  waters  of  Carlsbad  in  Bohe- 
mia contain  large  quantities  of  sodium  sulphate,  and  no  magnesium  sulphate 
whatever.] 

[f  This  is  essentially  a  sulphuretted  and  sulphate  of  calcium  spring.] 


Iß4:  DISEASES  OF  THE  INTESTINES 

[Tlie  list  of  carbonate  of  calcium  springs  in  the  United  States  is 
too  long  to  be  even  detailed  here.  A  number  of  tliem  contain 
considerable  quantities  of  this  salt.  All  the  Saratoga  waters  have 
it  in  amounts  ranging  from  0.72  gram  to  the  litre  (Empire  and 
Eureka  Springs)  to  2.9  grams  (Geyser  Spouting  and  Hathorn)  and 
3.9  (Champion  Spouting).*  Other  waters  of  this  class  are  the 
Americanus  Mineral  Well  (formerly  Michigan  Congress),  with  1.4Y 
grams  per  litre;  California  Seltzer,  with  1.25  gram;  Montesano 
(Missouri),  1.2  grams;  (Tolenas  (California),  0.85  gram;  Sans 
Souci  Springs  (Ballston  Spa,  N.  T.),  0.74  gram ;  Akesion  (Sweet 
Springs,  Mo.),  0.69  gram;  and  the  Soda  (Summit  Springs,  Cal.), 
0.65  gram  to  the  litre.  To  mention  a  few  others  with  lesser 
amounts  of  calcium  carbonate,  there  are  the  Geneva  Lithia,  the 
Adirondack,  and  the  Avon  Sulphur  (Lower)  Springs  of  Xew  York ; 
the  Kickapoo  and  Indian  Springs  of  Indiana ;  the  Sheboygan  and 
Leslie  of  Michigan ;  the  Boiler  (bathing)  and  Soda  (drinking)  of 
Yirgiuia  Hot  Springs  ;  the  Koyal  George  of  Colorado,  Waconda  of 
Kansas,  Crocker  of  Tennessee,  Old  Sweet  of  "West  Yirginia,  the 
Upper  and  Lower  Blue  Lick  of  Kentucky,  the  Bartlett  of  Cali- 
fornia, etc.] 

The  Iron  or  Chalybeate  Waters. — These  contain  carbonates  as 
well  as  sulj)hate  of  iron,  and  have  a  tendency  to  diminish  secretion 
in  the  body.  They  are  especially  useful  in  chronic  diarrhoea  or 
intestinal  catarrhs  with  diarrhoea,  of  which  anaemia  is  the  causative 
factor.  The  best  known  carbonated  chalybeate  waters  are  Franzens- 
bad, Elster,  Driburg,  Reinerz,  Rippoldsau,  Pyrmont,  Schwalbach, 
and  Cudowa.  Of  sulphate-of-iron  waters  we  may  mention  Konneby 
in  Sweden,  Levico  and  Koncegno  waters,  and  the  Guber  Spring. 

[Many  waters  of  this  countiy  have  been  found  upon  analysis  to 
be  very  good  chalybeates.  Combining,  as  many  of  them  do,  a 
goodly  proportion  of  other  minerals  (sodium,  magnesium  and  cal- 
cium, chlorids,  carbonates,  and  sulphates),  they  are  seen  to  be  most 
excellent  mineral  waters.  But  a  limited  number  can  be  mentioned  ; 
an  analysis  and  other  details  will  be  found  in  works  devoted  to  the 
subject  of  mineral  waters  (Crook,  A.  ]^.  BelP,  Walton^,  etc.). 
Xamed  in  the  order  of  their  percentage  of  carbonate  of  iron,  we 
have  the  Iowa  White  Sulphur  Springs ;  the  Chittenango  Sulphur 
Springs  of   ISTew  York    (Magnesia    Spring) ;   the    Owasso    Spring 

[*  In  addition  to  the  amount  of  calcium  carbonate  here  stated,  the  Saratoga,  as 
well  as  all  the  other  waters  of  this  class,  contain  considerable  proportions  of  mag- 
nesium carbonate. — Tr.] 


THE   HYDROTHERAPEÜTICS   OP  INTESTINAL   DISEASES      165 

(Michigan) ;  the  Pacific  Congress  (Cahfornia) ;  the  Sparta  Mineral 
Wells,  Wisconsin  (Magnetic  Mineral  Well) ;  ISTapa  Soda  Springs 
and  Mono  Lake  of  California  ;  Fruit  Port  Well  (Michigan)  ;  Sara- 
toga Springs,  New  York  (Putnam,  Columbia,  Hamilton,  Excelsior, 
and  Eureka  Springs) ;  Wilhoit's  Soda  Springs  (Oregon) ;  Ballston 
Spa  (Sans  Souci)  and  the  Adirondack  Spring  of  'New  York ; 
Arrington  Springs  (Nos.  1  and  2),  Kansas;  Americanus  Mineral 
Well  (Michigan) ;  Massanetta  Springs  (Virginia),  etc. 

The  following  are  the  principal  waters  containing  the  sulphate 
of  iron ;  they  are  arranged  according  to  amount  of  that  salt  found 
in  them :  The  Overall  Mineral  Wells  (Nos.  2  and  1)  of  Texas ;  the 
Oak  Orchard  Acid  Springs  (No.  2)  of  IN^ew  York ;  Gaylord  and 
Garlick's  Mineral  Springs  of  Pennsylvania ;  Bath  Alum  Springs  (Xo. 
2)  of  Yirginia ;  Indian  Springs  (Indiana);  Bedford  Alum  Springs 
(Virginia) ;  Texas  Sour  (or  Caldwell's)  Springs ;  Austin's  Springs 
(Tennessee) ;  Iron  Lithia  Springs  (Yirginia) ;  Wilbur's  Springs 
(California) ;  Fauquier's  White  Sulphur  Springs  (Yirginia),  etc. 
In  addition,  sulphate  of  iron  has  been  found  in  a  number  of  the 
California  geysers  in  amounts  ranging  as  high  as  0.49  gram  to  the 
litre. 

jFree  sulphuric  acid  is  found  in  the  Oak  Orchard  Springs  (about 
2.25  grams  per  litre) ;  the  Texas  Sour  Springs  (0.124  gram  per 
litre) ;  the  Gaylord  and  Garlick,  the  Iron  Lithia,  and  Bath  Alum 
Springs  (about  0.086  gram  per  litre)  ;  the  Bedford  Alum  (about 
0.068  gram  per  litre) ;  and  owing  to  its  acid  reaction  is  probably 
also  present  in  the  Overall  Mineral  Wells  (Crook).] 

In  some  cases — I  believe  in  far  too  few — enemata  of  mineral 
water  are  made  use  of.  For  this  purpose  the  thermal  waters  of 
Carlsbad,  Ems,  Wiesbaden,  and  ISTeuenahr  are  especially  appro- 
priate, particularly  if  there  exist  a  catarrhal  affection  of  the  lower 
segments  of  the  intestines.  Pollatschek^,  more  than  any  one  else, 
has  reported  very  favourable  results  from  small  enemata  (100  to 
200  cubic  centimetres)  of  warm  mineral  waters  in  chronic  catarrh 
of  the  large  intestine  and  in  ulcerative  processes  and  intestinal  neu- 
roses. I  should  think  that  small  quantities  of  chalybeate  waters  per 
rectum  might  be  useful  in  these  cases  in  which  iron  is  not  well 
borne  by  the  stomach. 

If,  after  this  brief  resume,  we  next  ask  ourselves  what  practical 
benefits  are  to  be  derived  from  the  use  of  the  above-named  mineral 
waters,  we  shall  find  it  very  difficult  to  answer  our  question  satis- 
factorily. 
12 


IQQ  DISEASES  OF  THE  INTESTINES 

As  already  mentioned,  so  many  subsidiary  factors  are  to  be 
taken  into  account  that  it  is  difficult,  if  not  impossible,  to  clearly 
define  their  individual  action.  Notwithstanding  this,  the  following 
statements  are  probably  correct.  To  simplify  matters  let  us  classify 
the  most  frequent  intestinal  affections  as  chronic  catarrhs  of  the 
large  and  small  intestines,  chronic  constipation,  and  chronic  diar- 
rhoea. It  would  be  correct  also  to  distinguish  between  mild  and 
severe  types,  but  such  a  division  depends  largely  upon  subjective 
impressions. 

In  the  milder  catarrhs  of  the  small  intestine  I  have  seen  excellent 
permanent  as  well  as  temporary  results  from  the  thermal  waters  of 
Carlsbad.  These  cases  are  unsuitable  for  the  cold  sodium  sulphate, 
the  muriated,  or  the  carbonated  springs.  The  warm  Carlsbad 
waters  are  also  most  beneficial  in  mild  catarrhs  of  the  large  intes- 
tine^ associated  with  constipation  or  with  constipation  alternating 
with  diarrhoea.  l!^ext  to  these  waters,  the  cold  sodium  sulphate  and 
the  warm  and  cold  muriated  waters  give  the  best  results.  Good 
results  are  sometimes  obtained  from  the  waters  of  Ems. 

Positive  benefit  may  be  expected  in  hemorrhoids  from  the  use 
of  the  Glauber  salt  watei's  (particularly  Marienbad),  as  well  as  from 
the  cold  muriated  waters  (especially  Kissingen,  Homburg,  and  Mer- 
gentheim).  The  effect  is  frequently  permanent ;  usually,  however, 
the  course  of  waters  must  be  repeated.  Water  treatment  in  mild 
cases  of  habitual  constipation  is  fairly  satisfactory.  These  are 
sometimes  permanently  relieved  by  the  sodium  sulphate  and  muri- 
ated waters,  but  generally  the  relief  is  only  temporary. 

Improvement  may  be  expected  in  chronic  diarrhoea  from  the 
use  of  the  Carlsbad  waters  (the  Sprudel  in  small  amounts),  the 
muriated  waters  (small  doses  warmed),  and  from  the  waters  of  Ems. 

The  above-mentioned  calcareous  waters  are  very  useful  in 
chronic  diarrhoea,  although,  strange  to  say,  they  are  very  little  used 
for  this  purpose.  In  combination  with  a  suitable  diet  I  obtain 
good  results  from  their  use.  From  an  extended  personal  experi- 
ence I  can  warmly  recommend  the  Marienbad  Rudolfsquelle,  the 
Coburg  Mariannenquelle,  and  the  Lippspringer  Arminiusquelle. 

Seigere  forms  of  intestinal  catarrh,  constipation,  and  diarrhoea 
are  less  likely  to  be  benefitted  by  a  course  of  mineral  waters.  The 
results  are  either  temporary  or  entirely  negative.  Of  the  many 
hundreds  of  private  patients  who  have  drunk  the  sulphated  or  the 
muriated  waters  at  the  original  springs,  I  have  not  yet  seen  one 
who  has  derived  any  permanent  benefit  from  the  waters  themselves. 


THE   HYDROTHBRAPEUTICS   OF   INTESTINAL   DISEASES      167 

I  could  note  an  inaprovement  only  in  those  patients  wlio  had  other 
treatment,  and  for  whom,  therefore,  the  drinking  of  the  waters 
was  really  superfluous. 

The  cause  of  failure  in  these  cases  is  very  clear.  Proper  regu- 
lation of  the  diet  is  the  main  factor  in  the  treatment  of  the  severer 
types,  and  not  even  in  a  place  so  well  organized  as  Carlsbad  is  this 
feature  as  thoroughly  attended  to  as  is  necessary.  Rest  in  bed  for 
a  longer  or  shorter  period  is  essential  to  the  cure  of  the  severer 
forms  of  chronic  diarrhoea  and  of  the  intestinal  catarrhs  that  cause 
them.  It  is  very  difficult  or  even  impossible  to  obtain  this  in  a 
watering  place,  unless  the  latter  contains  a  sanitarium  such  as  have 
of  late  been  successfully  introduced  in  various  watering  places. 
From  this  it  follows  that  only  mild  and  very  recent  cases  are 
adapted  to  a  course  of  water  treatment ;  all  others  should  be 
treated  in  a  sanitarium  or  a  hospital.  Since  a  number  of  mineral 
watering  places  (e.  g.,  Kissingen,  Wiesbaden,  Carlsbad,  Baden- 
Baden,  etc.)  have  now  well-conducted  private  institutions  in  which 
proper  regulation  of  the  diet  can  be,  wherever  necessary,  combined 
with  mechanical  therapeutic  measures  such  as  massage,  intestinal 
irrigations,  etc.,  we  can  now  send  even  severe  and  protracted  cases 
away.  There  are  more  such  private  sanitaria  throughout  Germany 
and  Switzerland,  but  as  it  is  impossible  to  commend  them  all  in 
this  place  we  refrain  from  mentioning  any.* 

Is  the  benefit  to  be  derived  in  mild  cases  sufficient  to  warrant  a 
patient  in  moderate  circumstances  incurring  the  heavy  expenses  of 
such  a  cure  ?  Where  a  permanent  cure  can  not  be  anticipated — and 
this  is  true  in  the  majority  of  cases — it  is  best  to  advise  against  such 
treatment.  With  the  wealthier  classes  it  is  quite  different,  for  they 
visit  the  baths  every  year,  either  from  custom  or  in  order  to  recu- 
perate from  the  trials  of  winter  society.  It  matters,  therefore,  very 
little  to  them  whether  they  derive  any  benefit  from  the  course  of 
waters  or  not.  At  all  events,  it  is  wrong  to  promise  any  patient  a 
permanent  cure  of  his  intestinal  trouble  from  a  four  weeks'  course 
at  a  mineral  spring.  Unfortunately,  the  physician  is  too  optimistic 
regarding  the  effects  of  mineral  waters,  and  it  is  not  surprising, 
therefore,  that  failure  to  obtain  such  results  is  explained  upon  the 
ground  that  "  the  wrong  spring  was  selected." 

Mineral  waters  are  often  drunk  at  the  home  of  the  patient.    This 


*  A  fairly  complete  list  will  be  found  in  Penzoldt-Stintzing's  Handbuch  d.  spe- 
ciellen  Therapie  innerer  Krankheiten,  1.  Aufl.,  Bd.  iv,  S.  274. 


Ißg  DISEASES   OF   THE  INTESTINES 

is  advisable,  if  at  the  same  time  it  can  be  combined  with  proper 
dieting  and  also  a  certain  amount  of  rest  and  freedom  from  daily 
occupation.     It  is  also  useful  as  a  preliminary  test  in  doubtful  cases, 

2.  Baths. — Yery  often  baths  are  given  in  connection  with  a 
coarse  of  mineral  waters  and  may  even  constitute  the  main  part  of 
the  treatment.  They  are  classed  as  natural  baths,  iron,  salt-water,  and 
mud  ["  moor"]  baths.  The  last-mentioned  variety  are  very  impor- 
tant in  the  treatment  of  chronic  exudative  processes  about  the  intes- 
tines. The  mud  baths  of  Marienbad,  Franzensbad,  and  Elster  are 
the  most  popular  ones.*  Salt-water  baths  are  found  inland  in  low  as 
well  as  in  mountainous  regions  (Reichenhall,  Kosen,  Salzungen,  etc.) 
and  at  the  seashore  (Colberg,  Swinemünde,  etc.).  There  can  be  no 
doubt  as  to  the  favourable  influence  of  these  baths  upon  many  cases. 
Thus  in  perityphlitic  exudations  I  have  occasionally  observed  re- 
markable benefit  follow  the  use  of  salt-water  baths.  For  a  com- 
bination course  of  mineral  waters  with  salt-water  bathing  Kissingen 
and  Wiesbaden  are  good ;  for  a  course  of  waters  with  mud  baths, 
Marienbad,  Elster,  Franzensbad,  and  Pyrmont  are  best. 

3.  Climatological  Treatrnent  (Seashore  and  Mountain  Air). — 
This  may  be  recommended  alone,  or  may  also  be  combined  with  a 
<30urse  of  mineral  waters.  Without  doubt  climatic  treatment  is  best 
adapted  to  nervous  affections  of  the  intestines.  It  is  very  often  also, 
and  quite  correctly,  advised  as  an  after  treatment  to  a  course  of 
waters.  The  physician  will  very  frequently  have  to  decide  for  his 
patient  between  seashore  and  mountain  air.  This  question  can 
only  be  considered  for  the  individual  case  ;  very  frequently,  indeed, 
equally  valuable  results  may  be  obtained  from  either  region.  As  a 
rule,  patients  whose  ordinary  vocation  inclines  them  to  sedentary 
habits  should  be  sent  to  the  mountains ;  while  those  living  in  large 
inland  cities  and  accustomed  to  excitement  and  running  about,  and 
to  gross  irregularities  in  eating  and  drinking,  should  be  sent  to  the 
seashore.  On  the  other  hand,  those  suffering  from  organic  intesti- 
nal disorders  should  not  be  sent  to  the  seashore  or  to  the  moun- 
tains. I  would  warn  against  permitting  patients  suffering  from 
chronic  intestinal  catarrhs  to  partake  of  tahle  (PhSte  meals  such  as 
are  ordinarily  served  at  the  seashore  or  in  the  mountains.  As  al- 
ready mentioned,  it  is  often  possible  to  combine  cold-water  treat- 

[*  In  the  United  States  mud  baths  are  given,  among  other  places,  at  the 
Arkansas,  Virginia,  and  Las  Vegas  Hot  Springs,  At  these  resorts  elaborate  bath- 
ing establishments,  modelled  after  those  in  vogue  at  the  most  celebrated  European 
watering  places,  have  been  established. — Tß.] 


THE  HYDROTHERAPEUTICS   OF  INTESTINAL   DISEASES      169 

ment  witb  a  sojourn  in  the  mountains,  and  in  suitable  cases  we 
ought  to  take  advantage  of  this.  Owing  to  the  enormous  number 
of  seaside  and  mountain  resorts  in  Germany  and  in  foreign  coun- 
tries, it  is  impossible  to  give  even  a  partial  list  of  them. 


LITERATURE 

1.  Pollatschek.     Wiener  med.  Wochenschr. ,  1891,  No.  23. 

[3.  A.  N.  Bell.     Climatology  and  Mineral  Waters  of  the  United  States,  New 

York,  1885.] 
[3.  Walton.     Mineral  Springs  of  the  United  States  and  Canada,  1873.] 


CHAPTER   X 

MASSAGE.      ELECTRO-  AND  HYBUO THERAPEUTICS   IN 
INTESTINAL  DISEASES 

1 .   Massage 

In  intestinal  diseases  massage  is  employed  to  stimulate  the  re- 
laxed muscles  of  these  organs,  and  to  cause  diffusion  and  absorption 
of  local  inflammatory  and  peritoneal  processes. 

The  most  frequent  indication  for  massage  is  furnished  by  atony 
of  the  intestines. 

Technic  of  Intestinal  Massage* 

In  order  to  relax  the  abdominal  walls  we  begin  with  rotary 
efleurage  (stroking).  In  stout  persons  this  is  followed  by  petris- 
sage (kneading),  the  object  being  the  crushing  of  individual  fat 
globules.  Petrissage  of  the  deeper  tissues  is  the  most  important 
manipulation  in  intestinal  massage. 

"  With  both  hands  we  grasp  the  intestines  through  the  abdominal 
walls,  and  as  though  we  were  handling  a  muscle  that  we  wished  to  ex- 
press, we  make  the  same  zigzag  forward  and  backward  movements 
that  we  would  in  kneading  such  muscle.  We  thus  proceed  over  the 
entire  abdomen.  The  next  step  is  to  stroke  the  fsecal  masses  out  of 
the  intestines.  We  begin  with  the  ascending  colon,  pass  upward, 
follow  to  the  left  along  the  transverse  colon,  and  then  continue 
downward  until  we  reach  the  sigmoid  flexure.  At  first,  stroking 
movements  are  made ;  later,  rotary  petrissage  is  substituted,  for  this 
acts  more  energetically  in  mechanically  removing  faecal  contents." 
Hoffa  describes  "rotary  petrissage"  (kneading)  as  follows:  "With 
the  hands  held  at  an  acute  angle  to  the  abdominal  wall,  and  with 
the  finger  tips  of  the  left  hand  resting  upon  those  of  the  right  and 

*  We  here  follow  the  description  given  by  Hoffa  in  his  Technik  der  Massage 
(Stuttgart,  1893),  to  which  work  the  reader  is  referred  for  all  further  details.    (Com- 
pare also  the  section  on  Massage  in  my  Diagnostik  und  Therapie  der  Magenkrank- 
heiten, Part  I,  p.  324,  fourth  edition.) 
170 


MASSAGE 


m 


directed  upward  toward  the  chest,  rotary  movements  are  made  in 
the  ileo-csecal  region  [Fig.  22].  Since  sudden  pressure  would  result 
in  rigidity  of  the  abdominal  walls,  the  rotary  movements  must  be 
gentle,  the  deeper  parts  being  very  gradually  approached.  The 
movement  is  the  same  that  we  make  in  palpating  deep-seated  ab- 
dominal tumours.     The  patient  is  told  to  breathe  deeply,  and  with 


[Fig.  22.— Position  of  Hands  and  Direction  of  Movements  in 
Intestinal  Massage  (Hoffa). — Tr.] 

each  expiration  we  press  deeper.  The  advancing  movement  on  the 
part  of  the  operator  proceeds  directly  from  the  shoulder  joint,  while 
the  finger,  wrist,  and  elbow  joints  should  be  held  almost  rigid." 

Tapotement  {percussion)  and  vibrations  of  the  abdominal  wall 
follow  the  deep  petrissage.  These  tend  to  stimulate  the  smooth 
muscles  of  the  intestines,  and  to  promote  alterations  in  the  circula- 
tion in  the  blood-vessels. 

Besides  atony  of  the  intestines  (especially  that  associated  with 
flatulence),  massage  is  beneficial  in  localized  peritonitic  processes 
about  the  intestines,  particularly  in  perityphlitis  or  appendicitis  after 
the  acute  stage  has  passed.  In  these  cases  the  greatest  care  must  be 
taken.  Above  all,  we  should  make  it  a  strict  rule  never  to  begin 
massage  until  weeks  after  all  inflammatory  manifestations  have  dis- 
appeared. The  regions  of  the  caecum  must  no  longer  be  sensitive 
to  pressure.  It  is  hardly  necessary  to  state  that  if  there  is  the  least 
suspicion  of  an  abscess  or  of  tubercular  appendicitis  massage  should 
never  be  attempted. 

This  last  precaution  applies  also  to  new  growths  of  the  intestinal 


172  DISEASES   OF   THE   INTESTINES 

tract,  benign  as  well  as  malignant.  I  would  also  warn  against 
employing  massage  in  intestinal  obstruction.  As  a  rule,  it  can  only 
add  to  the  gravity  of  the  condition. 

Each  sitting  should  last  ten  minutes,  and  no  single  manipulation 
should  require  more  than  two  or  three  minutes.  The  treatment 
should  lirst  be  conducted  daily  for  four  weeks;  after  that  every 
two  or  three  days  for  four  to  six  weeks.  In  constipation  the  results 
from  massage  will  vary  largely,  for  they  depend  upon  the  degree  of 
the  intestinal  difficulty,  as  well  as  upon  the  patience  of  the  subject, 
and  above  all  upon  the  skill  of  the  masseur.  My  own  experiences 
in  the  matter  have  led  me  to  form  the  following  conclusions :  A 
permanent  result  (i.  e.,  regular  and  sufficient  intestinal  evacuations) 
can  be  obtained  from  properly  conducted  massage  combined  with 
therapeutic  measures  which  tend  to  bring  about  the  same  result — 
i.  e.,  diet,  gymnastics,  electricity,  rowing,  turning,  and  other  bodily 
exercises. 

On  the  other  hand,  in  some  cases  of  intestinal  atony  I  doubt  very 
much  whether  massage  alone  can  give  more  than  temporary  relief. 
Yery  soon  after  the  discontinuance  of  the  massage,  even  though 
applied  for  weeks  by  an  experienced  person,  the  intestine  usually 
fails  to  properly  perform  its  functions.  This  result  is  quite  con- 
trary to  that  obtained  from  the  above-mentioned  diet  (page  000), 
where  in  the  vast  majority  of  cases  a  permanent  effect  is  secured, 
continuing  even  when  the  diet  regime  is  no  longer  strictly  followed. 
We  do  not  deny  that  exceptions  do  occur,  but  these  do  not  alter  the 
general  rule. 

Regarding  massage  in  localized  peritonitis,  I  can  say  but  very 
little,  for  my  experience  has  not  been  extensive.  I  am,  however,  in 
favour  of  a  trial  under  the  above-mentioned  precautions.  At  times 
considerable  benefit  may  be  derived  from  the  combination  of  mas- 
sage with  indoor  gymnastics,  such  as  have  been  introduced  by  G. 
Zander.  This  is  not  the  place  to  enter  into  a  description  of  such 
gymnastics,  especially  as  they  can  only  be  learned  through  practical 
experience. 

2.    Electrical  Treatment 

This  includes  the  use  of  the  faradic,  the  galvanic,  and  the 
galvano-faradic  (mixed)  currents.  The  application,  as  in  the  stom- 
ach, may  be  either  external  or  intra-abdominal,  or,  more  correctly 
speaking,  rectal.  At  present  opinion  is  very  much  divided  as  to 
whether  galvanism  or  faradism,  or  their  combination,  is  more  bene- 


ELECTRICAL   TREATMENT  173 

ficial,  and  also  as  to  whether  the  extra-abdominal  or  intrarectal 
method  gives  the  best  results.  In  fact,  some  authors  regard  the 
application  of  electricity  to  the  intestines  as  utterly  useless. 

Our  scientific  knowledge  regarding  the  action  of  the  electric 
current  upon  the  intestines  is  very  limited.  We  know  that  visible 
and  palpable  intestinal  movements  can  be  produced  in  persons  with 
thin  abdominal  walls  or  with  inguinal  Hernia  (von  Ziemssen).  In  a 
case  of  peristaltic  restlessness  under  my  observation  we  could  detect 
a  temporary  increase  of  the  intestinal  peristalsis.  The  only  sys- 
tematic experiments  were  those  of  Schillbach  ^  upon  exposed  rab- 
bits' intestines  kept  in  a  bath  of  normal  salt  solution.  His  results 
would  seem  to  indicate  that  the  faradic  and  the  galvanic  currents 
differ  in  their  effects  upon  intestinal  peristalsis,  inasmuch  as  a  faradic 
current  of  medium  strength  causes — particularly  in  the  small  intes- 
tine and  less  so  in  the  large — ascending  and  descending  waves  of 
contraction  of  a  few  centimetres  of  the  stimulated  bowel.  With  the 
galvanic  current  he  observed  localized  contractions  at  the  cathode, 
and  peristaltic  waves  of  contraction  at  the  anode.  In  view  of  these 
observations,  Leubuscher^  and  Schillbach  particularly  recommend 
the  employment  of  intrarectal  galvanization  (anode  on  the  abdom- 
inal wall,  cathode  in  the  rectum),  and  from  their  experience  they 
believe  galvanization  gives  better  results  than  faradization.  There 
is  considerable  discrepancy  between  the  views  of  authorities  on  the 
efficiency  of  electro -therapeutic  measures.  I^othnageP  considers 
electrization  of  the  intestine  less  beneficial  than  massage;  Ewald*, 
too,  sees  little  or  no  use  from  electricity  in  intestinal  diseases.  On 
the  other  hand,  Eichhorst  ^  reports  a  case  in  which  unsuccessful 
attempts  were  made  for  eight  days  to  secure  a  movement  of  the 
bowels,  and  in  which  a  single  application  of  the  faradic  current  was 
followed  by  copious  evacuations  and  complete  cure  of  the  patient. 
Unfortunately,  the  nature  of  the  obstruction  (fsecal  impaction  ?)  can 
not  be  determined  with  certainty  from  the  published  reports  of  these 
cases. 

I  should  like  to  describe  the  technic  of  intestinal  electrization 
before  speaking  of  the  results  gained  from  my  own  experience. 
For  external  application  either  broad  electrodes  are  to  be  employed 
or  electric  rollers  or  brushes.  As  in  the  electrical  treatment  of  the 
stomach,  so  in  intrarectal  electrization,  I  have  many  years  employed 
a  soft-rubber  tube,  with  numerous  perforations  near  its  tip  and  with 
a  platinum  spiral  in  its  interior  (Fig,  23).  In  addition  to  the  switch 
for  making  and  breaking  the  current,  the  upper  part  also  is  provided 


174 


DISEASES  OF  THE  INTESTINES 


with  a  small  tube  for  the  in-  and  outflow  of  water.  The  filling  of 
the  rectum  is  accomplished  in  the  usual  manner  bj  a  funnel  and 
rubber-tube  attachment.  From  100  to  200  cubic  centimetres  of 
lukewarm  water  are  allowed  to  flow  into  the  bowel.  The  other  elec- 
trode is  placed  upon  the  abdomen  and  is  moved  along  the  entire 
course  of  the  large  intestine.  Each  application  should  last  ten 
minutes.  The  faradic  current  can  be  applied  strongly  enough 
to  produce  distinct  visible  muscular  contractions  ;  the  patient 
should  experience  a  definite  and  barely  painful  prickling  sensa- 
tion. Twenty  to  thirty  milliamperes  of  the  galvanic  current  will 
sufiice. 

My  personal  experience  is  limited  almost  entirely  to  intrarectal 
faradization.      My  conclusions  are  to  be  considered  all  the  more 

trustworthy  because  I  resort  to  intesti- 
nal electrization  only  when  other  means 
have  failed  (i,  e.,  in  the  most  obstinate 
cases),  and  I  seldom  combine  different 
methods  of  treatment.  I  can  state  that 
intrarectal  treatment  succeeds  in  tnany 
of  the  cases  in  which  nothing  at  all 
could  he  accomplished  by  massage^  diet^ 
or  gymnastics.  The  patients  have  well- 
formed  movements  daily.  We  can  ex- 
clude any  possible  action  from  the  water, 
for,  aside  from  the  fact  that  it  is  with- 
drawn through  the  tube  at  the  termina- 
tion of  each  electrical  application,  those 
cases  of  constipation  in  which  I  employ 
intrarectal  faradization  are  of  such  an 
obstinate  nature  that  small  enemata  of  water  have  no  effect  what- 
ever. Besides  this,  defecation  does  not  immediately  follow  rectal 
faradization,  but  frequently  occurs  only  after  many  hours.  In 
some  cases  a  permanent  benefit  is  obtained,  in  others  the  patients 
are  compelled  for  months  to  use  the  electric  rectal  sound.  Aside 
from  the  so-called  auto-massage,  which  is  hardly  deserving  of  seri- 
ous attention,  electrization  has  the  advantage  over  massage  that  any 
intelligent  patient  can  employ  it  for  months  on  himself. 

The  use  of  the  electric  current  is  therefore  generally  indicated 
in  paresis  of  the  intestinal  muscle  ;  its  most  important  sphere,  how- 
ever, lies  in  those  forms  of  habitual  constipation  in  which  over-dis- 
tention  of  the  ampulla  recti  had  gradually  led  to  paresis  of  the  rectal 


Fig.  23. — ^Electrtc  Eectal  Tube. 


HYDROTHERAPEUTIC   MEASURES  175 

muscles  and  sphincters.  In  this  condition,  skilfully  applied  elec- 
trical treatment  will,  as  I  have  repeatedly  convinced  myself,  result 
in  permanent  benefit  to  the  patient. 


3.   Hydrotherapeutic  Measures 

In  diseases  of  the  intestines,  use  is  made  of  external  and  inter- 
nal hydrotherapeutic  measures.  The  internal  ones  are  mostly 
limited  to  the  use  of  water  in  the  rectum,  and  owing  to  their  great 
practical  importance  will  he  treated  of  separately  elsewhere.  In 
the  following  we  will  consider  external  hydrotherapeutics  only.  Of 
these  we  employ : 

1.  Moist  Apjplications. — These  may  be  cold,  warm,  so-called 
"  Priessnitz  "  (moist)  applications  and  poultices.  The  former  class 
exert  a  stimulating,  the  latter  a  sedative,  action  on  the  bowel.  The 
Priessnitz  pack  while  cold  stimulates,  and  later  exerts  a  sedative 
influence  on  the  gut.  Hot  bran  poultices  relieve  pain,  probably 
owing  to  the  fact  that  the  heat  causes  a  momentary  paralysis  of  the 
sensitive  nerve-endings.  Hot  or  cold  water  bottles  or  water  bags 
may  be  used  instead  of  moist  applications ;  in  general  practice,  clay 
bottles  filled  with  hot  water  and  wrapped  in  flannel  or  some  such 
impermeable  material  sufiice.  In  place  of  hot  bran  poultices,  I 
have  long  used  pieces  of  felt  dipped  in  hot  water  and  then  covered 
with  an  impermeable  material. 

2.  Baths. — These  are  classed^  as  full  baths,  half  baths,  and  sitz 
baths,  all  of  which  can  be  given  at  varying  temperatures  and  com- 
bined with  other  hydriatic  measures. 

3..  Douches. — These  are  given  in  the  form  of  cold  or  warm  or 
of  alternating  hot  and  cold  (Scotch)  douches.  They  are  classed  as 
shoimr,  needle,  jet,  and  vapour  douches. 

4.  Cold  or  Lukewarm  Applications,  with  Friction,  etc. — In  most 
cases  these  different  procedures  are  combined  in  various  ways,  and 
frequently  electricity  or  massage  is  given  in  connection  with  them. 
It  would  be  out  of  place  to  enter  into  a  detailed  description  of  these 
here.  External  hydrotherapeutic  measures  are  mainly  indicated  in 
chronic  and  benign  intestinal  affections— i.  e.,  catarrhs  and  neuroses. 
Intestinal  neurasthenia  in  particular  is  often  very  much  benefitted 
\)j  hydriatic  treatment.  At  the  present  day  hydrotherapeutic  treat- 
ment is  applied  almost  exclusively  in  institutions,  and  its  results  are 
in  part  due  to  the  water  applications,  but  more  so,  in  many  cases,  to 
the  personality  of  the  conductor  of  the  institute.     It  can  be  readily 


-[Y6  DISEASES   OF  THE  INTESTINES 

understood  that  those  institutions  are  best  which  provide  an  indi- 
vidualized diet  regime. 


LITERATURE 

1.  Schillbach.     Virchow's  Archiv,  Bd.  cix,  1887,  S.  278. 

2.  Leubuscher.     Centralbl.  f.  klio.  Medicin,  1887,  No.  25. 

3.  Nothnagel.     Die  Erkrankungen  des  Darms.  Wien,  1895,  S.  42. 

4.  Ewald.     Berliner  Klinik,  Heft  105,  1897. 

5.  Eichhorst.     Handbuch  d.    speciellen  Pathologie    u.   Therapie,   4te   Aufl., 

1890,  Bd.  ü,  S.  264. 


CHAPTER  XI 

INJECTIONS  (ENEMATA,  INTESTINA!  LAVAGE,  AND  DOUCHES), 
INFLATION,  AND  GASTRIC  LAVAGE  IN  INTESTINAL  DIS- 
EASES 

1.    Injections  (Enemata,  Intestinal   Lavage,  and  Douches) 

Injections  are  employed  for  various  purposes  : 

1.  To  stimulate  peristaltic  action,  or  by  softening  hardened  faeces 
to  facilitate  their  removal. 

2.  As  intestinal  lavage,  {a)  for  the  removal  of  pathological  sub- 
stances (mucus,  blood,  and  pus);  (5)  for  the  purpose  of  irrigating 
the  mucous  membrane  with  watery  solutions  of  medical  substances. 

3.  Mechanically  to  remove  concrements  and  foreign  bodies. 

4.  As  douches,  to  strengthen  and  stimulate  the  paretic  intestinal 
muscle. 

Technic. — Nowadays  enemata  are  given  either  by  means  of  an 
irrigator  consisting  of  a  reservoir  of  varying  material  (rubber,  glass, 
or  metal)  connected  by  rubber  tubing,  the  so-called  rectal  tube  ;  or 
else  by  means  of  Hegar's  apparatus,  in  which  the  reservoir  is 
formed  by  a  glass  or  rubber  funnel.  The  irrigator  is  better  adapted 
for  use  by  the  patient  himself  than  is  Hegar's  apparatus,  but  the 
latter  is  far  more  preferable  for  the  giving  of  an  enema  by  a  second 
person,  since  it  permits  him  to  regulate  the  pressure,  and  in  case  of 
too  much  distention,  by  simply  lowering  the  funnel,  to  let  any 
desired  amount  of  water  or  air  out  of  the  intestine.  For  auto- 
irrigations  I  recommend  an  irrigator  holding  3  litres,  which  is 
fastened  to  a  support,  and,  like  the  well-known  Leube-Eosenthal 
apparatus  for  gastric  lavage,  is  also  furnished  with  a  T-shaped  tube. 
According  to  Quincke,  the  rectal  tube  is  best  made  of  soft  rubber ; 
the  English  [French]  stiff  or  hard-rubber  tubes  are  decidedly  infe- 
rior to  it,  and  if  employed  at  all,  should  be  thick  and  rounded  off  at 
their  lower  end  and  provided  with  two  or  three  large  [lateral]  open- 
ings.    To  avoid  injury  to  the  parts,  all  rectal  instruments  should  be 

177 


178  DISEASES   OP   THE  INTESTINES 

smooth  and  free  from  cracks.  For  this  reason  soft-rubber  tubes 
are  to  be  preferred. 

In  place  of  the  above-mentioned  apparatuses  there  are  others 
adapted  to  auto-injections  per  rectum  (e.  g.,  the  so-called  injection 
pumps,  alpha  syringes,  etc.),  all  based  upon  the  principle  of  forcing 
water  into  the  rectum  under  a  certain  degree  of  pressure.  All  in 
all,  the  value  of  these  and  similar  apparatuses  described  in  the  cata- 
logue of  instrument  makers  is  not  very  great.  Even  their  advantages 
for  use  during  travel  is  questionable.  I  would  emphasize,  better  re- 
sults are  not  obtained  with  these  than  with  the  irrigator  or  funnel. 
As  regards  the  technic  of  giving  or  taking  an  enema,  in  the  first  place, 
one  must  have  a  definite  idea  of  the  object  in  view.  If  it  be  desired 
to  act  upon  the  colon  in  order  to  stimulate  peristalsis,  this  is  best 
done  with  the  rectum  as  empty  as  possible.  The  method  employed 
is  similar  to  that  used  in  giving  an  intestinal  douche,  to  the  discus- 
sion of  which  we  refer  the  reader  for  technic  and  indications. 

For  the  removal  of  hardened  faecal  masses  from  the  intestine, 
we  employ  thermal,  mechanical,  chemical,  or  electrical  methods, 
singly  or  combined. 

Thermal  stimuli  consist  in  the  injection  of  cold  fluids  of  a  tem- 
perature of  18°  C.  [65°  F.]  or  less.  Sometimes  irrigations  of  ice 
water  are  recommended — e.  g.,  in  bleeding  from  hemorrhoids — but 
such  measures  are  not  without  danger. 

The  mechanical  effect  is  obtained,  in  the  first  place,  from  the 
introduction  of  the  instrument  itself,  and,  secondly,  from  the  in- 
jected water. 

The  purpose  of  chemical  agents  is  either  to  exert  an  infiuence 
upon  the  intestinal  wall  or  to  soften  hardened  faeces. 

The  effect  of  intrarectal  electrical  treatment  has  already  been 
described  on  page  174. 

It  is  not  easy  to  state  which  of  these  methods  is  the  best.  In 
some  cases— i.  e.,  in  certain  stages  of  constipation — one  apparently 
obtains  good  results  from  any  one  of  them.  Without  doubt,  indi- 
vidual idiosyncrasies  play  an  important  role  here  just  as  they  do 
in  the  medicinal  treatment  of  constipation.  I  shall  not,  therefore, 
enter  into  a  discussion  of  the  relative  value  of  the  various  methods 
in  use,  but  shall  confine  myself  to  those  which  my  experience  has 
taught  me  are  best. 

The  quantity  of  fluid  that  should  be  injected  into  the  rectum  is 
a  question  of  primary  importance.  It  is  clear  that  1  or  2  litres 
of  fluid,  when  injected  into  the  lower  portion  of  the  bowel,  will 


INJECTIONS  lY^ 

cause  an  acute  extreme  distention  of  the  intestine  and  a  resulting 
tenesmus,  so  that  the  greater  part  or  the  whole  of  the  fluid  is  expelled 
without  sufficient  purgative  action.  It  is  immaterial  whether  one 
uses  cold  or  warm  water,  oil,  vinegar,  soapsuds,  or  glycerin.  Even 
the  more  active  irritant  remedies  exert  an  insufficient  influence 
upon  the  bowel  when  they  remain  in  it  for  a  short  time  only.  If 
the  lowermost  portion  of  the  intestines  contain  fsecal  masses,  these 
will  be  forced  out  mechanically  with  the  water. 

The  general  rule  to  be  followed  in  the  majority  of  cases  is  this  : 
the  quantity  of  fluid  used  should  be  small,  not  exceeding  300  c.  cm., 
and  should  be  slowly  injected  under  slight  pressure.  It  is  best  to 
have  the  patient  lying  on  the  left  side  with  the  pelvis  raised. 
This  amount  of  fluid  should  be  retained  for  several  hours,  so  as 
to  cause  a  gradual  softening  of  the  intestinal  contents  or  a  stimula- 
tion of  the  smooth  muscle  fibers  of  the  bowel  wall.  I  generally 
leave  orders  to  have  these  enemata  given  at  night,  so  that  the  bowels 
move  the  next  morning,  or  else  given  in  the  morning,  so  as  to  obtain 
a  movement  in  the  evening.  Glycerin,  soap,  sugar,  honey,  etc., 
added  to  the  enema  increase  the  softening  effect  upon  the  faeces. 
Penzoldt's^  experience,  which  I  can  substantiate  throughout,  was 
that  soap  acted  most  energetically  in  this  respect,  and  oil  somewhat 
less  so.  Others  have  recommended  limewater  for  the  same  pur- 
pose. As  a  rule,  I  order  the  following  as  an  effectual  enema :  One 
teaspoonful  of  soap  shavings,  or  of  good  glycerin  soap,  dissolved  in 
a  quarter  of  a  litre  of  lukewarm  water  to  which  is  added  one  to 
two  tablespoonfuls  of  glycerin.  As  a  result  of  Fleiner's  ^  recom- 
mendation, oil  injections  of  from  400  to  500  c.  cm.  are  very  fre- 
quently used.  Fleiner  believes  that  it  is  very  important  to  use 
only  the  purest  oil,  and  for  this  purpose  he  has  especially  recom- 
mended sesame  oil.  The  disadvantage  of  the  method  is  that  fre- 
quently the  patient's  clothes  are  soiled  by  the  oil.  For  this  reason, 
and  also  because  the  oil  partly  adheres  to  the  walls  of  the  irrigator 
and  tube,  I  order  the  oil  to  be  used  in  the  form  of  an  emulsion,  and 
recommend  the  following  procedure  :  A  piece  of  soda  the  size  of  a 
bean  is  dissolved  in  a  quarter  litre  of  water ;  to  these  are  gradually 
added  two  tablespoonfuls  of  commercial  cod-liver  oil  and  the  mix- 
ture thoroughly  shaken ;  two  tablespoonfuls  of  castor  oil  are  then 
added,  and  the  whole  mixture  shaken  until  an  emulsion  has  been 
formed.  The  resulting  emulsion  readily  flows  through  the  irrigator, 
is  well  retained  by  the  patient,  and  even  in  the  most  obstinate 
cases  will  succeed  in  softening  hardened  faeces.     In  an  experience  of 


180  DISEASES  OP  THE  INTESTINES 

almost  ten  years  I  have  never  seen  any  irritation,  pain,  or  other 
unpleasant  symptoms  from  them,  and  I  therefore  warmly  recom- 
mend them. 

In  this  place  it  is  proper  to  discuss  "  high  enemata,"  concerning 
which  mnch  is  said  in  daily  practice,  and  to  the  mechanism  of 
which  due  consideration  is  seldom  paid.  We  have  already  noted 
that  rectal  tubes  can  seldom  be  introduced  beyond  the  sigmoid 
flexure  or  the  descending  colon,  since  they  are  generally  arrested  in 
the  sigmoid  flexure,  and  further  attempts  result  in  a  bulging  of  the 
intestinal  wall.  It  is  no  better  with  rigid  French  or  English  tubes 
than  with  the  soft  JSTelaton  tubes  ;  the  former  pass  more  readily  into 
the  sigmoid  flexure,  although  they  are  very  apt  to  be  arrested  by  the 
folds  of  this  portion  of  the  intestines.  We  see,  therefore,  that  the 
whole  question  of  the  so-called  high  enemata  is  in  many  respects  an 
illusion. 

Even  for  extensive  lavage  of  the  upper  portions  of  the  intestines 
it  is  not  necessary  to  introduce  the  tube  very  high.  By  means  of 
auscultation  one  may  convince  himself  that  even  when  the  tube  lies 
in  the  rectum  and  the  patient  is  properly  placed  (lying  on  his  [left] 
side  with  raised  pelvis,  or  in  the  knee-chest  position),  fluids  pass  as 
far  as  the  caecum. 

Irrigations  of  the  bowel  by  means  of  a  funnel  are  especially  use- 
ful for  the  removal  of  fsecal  masses  and  tightly  adherent  mucus 
from  the  large  intestine.  In  obstinate  constipation  I  have  had  very 
good  results  from  enemata  consisting  of  several  litres  of  soapsuds 
(with  the  addition  of  glycerin,  castor  oil,  and  cod-liver  oil  if  neces- 
sary). 

Indications  for  Enemata  and  Irrigations  of  the  Intestine. — Ene- 
mata are  most  frequently  used  in  acute  and  habitual  constipation. 
Regarding  their  usefulness  or  disadvantages  there  is  a  diversity  of 
opinion  among  physicians  and  laymen.  We  cannot  here  enter  into 
this  question.  From  my  own  experience,  I  believe  that  enemata 
have  a  wide  fleld  of  application  both  in  acute  and  in  habitual  con- 
stipation ;  when  properly  given  they  are  generally  successful.  They 
are  said  to  have  the  disadvantage  of  distending  the  large  intestine 
and  thus  increasing  its  atony.  This  is  certainly  true  where  very 
large  enemata  are  given.  When  given  as  recommended  by  us  this 
result  need  not  be  feared.  Therefore,  whenever  possible  in  habitual 
constipation  enemata  should  be  given  preference  to  laxatives.  An 
internal  laxative  is  best  in  acute  constipation  complicated  by  acute 
gastric  catarrh.     The  second  most  frequent  indication  for  enemata 


INJECTIONS  181 

is  chronic  catarrh  of  the  large  intestine  with  profuse  diarrhoeas  or 
excessive  mucus  formation.  Here  one  should  use  lukewarm  water, 
or,  better  still,  physiological  salt  solutions  or  solutions  of  medicinal 
agents.  The  latter  should  be  chosen  according  to  the  eifect  desired  ; 
thus  we  may  use  antiseptics  such  as  lysol,  boric  acid,  salicylic  acid, 
salicylate  or  benzoate  of  soda,  thymol,  etc,  or  astringents  such  as 
tannin,  aceto -tartrate  of  aluminium,  and  nitrate  of  silver,*  or  mucus 
solvents  such  as  boracic  acid,  or  bicarbonate,  carbonate,  or  acetate 
of  soda,f  or  limewater.  Here  intestinal  lavage  is  much  better  than 
enemata,  for  it  enables  us  to  first  cleanse  the  bowel  and  then  imme- 
diately thereafter  apply  our  medication.  If  tenesmus  occurs,  it  may 
at  once  be  allayed  by  lowering  the  funnel.  The  lavage  should  be 
repeated  once  or  twice  daily. 

A  further  indication  for  lavage  is  furnished  by  chronic  stenoses, 
where  these  are  not  caused  by  extensive  ulcerations  or  tumours 
which  tend  to  perforate.  Since  we  have  no  general  diagnostic  crite- 
rion for  these  conditions,  great  care  must  always  be  exercised — 
i,  e.,  avoid  great  pressure,  and  give  only  small  enemata,  frequently 
repeated.  Syringes  which  force  fluids  into  the  gut  should  never  be 
used.  While  the  effect  from  these  irrigations  is  mainly  palliative, 
skilful  application  may  occasionally  enable  us  to  relieve  a  sudden 
and  dangerous  total  intestinal  obstruction  arising  from  dietary  error 
— e.  g.,  impaction  of  indigestible  food  remnants. 

It  is  sometimes  possible  to  loosen  and  wash  out  gallstones,  cop- 
roliths,  or  swallowed  foreign  bodies  causing  an  obstruction.  In 
obstruction  from  gallstones  I  would  recommend  the  employment 
of  injections  of  chloroform  water  (10  :  1,000)  in  order  to  dissolve 
small  fragments  of  these  concrements.  This  should  be  done  under 
anaesthesia,  as  it  is  then  possible  to  pass  beyond  the  ileo-csecal  valve. 
I  have  not  had  any  practical  experience  in  the  matter. 

Furthermore,  enemata  are  indicated  in  acute  and  chronic  invagi- 
nations :  in  the  acute,  in  order  to  reduce  the  invagination ;  in  the 
chronic,  to  prevent  or  relieve  coprostasis  above  the  invaginated 
portion.  J^othnagel  especially  recommends  injections  of  5  to  8  per 
cent  saline  solutions,  and  bases  his  recommendation  upon  animal 
experiments,  in  which  he  found  that  physiological  invaginations  are 
overcome  by  saline  injections. 

*  We  use  one  teaspoonful  of  tannin,  boric  acid,  and  aceto-tartrate  of  aluminium, 
or  one  half  to  one  gram  of  silver  nitrate  to  the  litre  of  water, 

f  Bicarbonate,  carbonate,  or  acetate  of  soda  are  used  in  the  strength  of  one 
dessertspoonful  to  the  litre, 
13 


182  DISEASES  OP  THE  INTESTINES 

Intestinal  Douche. — In  the  intestinal  douche  we  have  a  means 
of  stimulating  and  strengthening  the  neuro-muscular  apparatus  of 
the  lower  portion  of  the  large  intestine.  Here,  as  in  the  stomach, 
we  employ  a  funnel  and  rubber  tube  armed  with  a  short,  soft,  Nek- 
ton rectal  tube,  the  end  of  which  contains  ten  to  fifteen  small  open- 
ings. The  tube  is  introduced  as  far  as  possible,  preferably  under 
the  guidance  of  the  finger.  Ordinary  cold  water,  or  cold  water 
alternating  with  hot,  is  employed,  or  we  may  also  use  water  charged 
with.  CO3.  As  already  mentioned,  it  is  best  to  have  the  rectum 
emptied  before  giving  the  douche. 

In  a  series  of  cases  of  atony  of  the  large  intestine,  especially  in 
those  in  which  scybala  were  retained  in  the  recesses  of  the  sigmoid 
flexure  and  the  amj^ulla  of  the  rectum  and  caused  marked  tenes- 
mus, this  procedure  has  proved  a  very  valuable  one. 

2.    Inflation  of  Air 

Inflation  of  air,  the  diagnostic  value  of  which  has  already  been 
discussed,  is  warmly  recommended  by  some  writers  as  a  means  of 
relieving  obstructions,  especially  of  the  lowermost  portions  of  the 
intestine.  Curschmann^,  in  particular,  has  often  spoken  in  favour 
of  intestinal  insufflation  in  cases  of  volvulus  of  the  sigmoid  flexure 
and  intestinal  stenoses,  and  he  prefers  it  to  the  injection  of  water. 
He  recognises,  however,  that  there  are  dangers  connected  with  the 
procedure,  and  therefore  advises  that  it  should  be  employed  with 
great  caution  in  specially  selected  cases.  The  recommendation  of 
Curschmann,  to  use  a  tube  of  such  a  form  as  to  permit  the  entry 
and  exit  of  air  at  will,  is  certainly  worthy  of  consideration.  It  is 
more  difficult  to  fulfil  Curschmann's  second  condition — namely,  the 
selection  of  suitable  cases.  Thus,  it  is  often  impossible  to  determine 
whether  ulceration  of  a  carcinoma  of  the  colon  has  occurred  and  if 
there  is  danger  of  rupture.  It  is  often  exceedingly  difficult  to  de- 
termine the  nature  of  a  stenosis.  I  believe  that  all  stenoses  due  to 
ulceration  or  tumours  constitute  a  contra-indication  to  insufilation 
with  air.  It  is  also  advisable  not  to  attempt  this  procedure  in 
invaginations  low  down,  as  one  can  never  determine  with  certainty 
how  far  the  process  has  advanced  (beginning  gangrene).  Careful 
insufflation  may  be  done  in  simple  volvulus  of  the  sigmoid  flexure 
when  the  diagnosis  is  certain. 


INJECTIONS  183 

3.    Gastric  Lavage  in  Intestinal  Diseases 

Gastric  lavage  in  intestinal  diseases  comes  up  for  consideration 
in  stenosis  or  stricture  of  the  bowel,  above  wbich  faecal  matter  has 
collected ;  also  where  fermenting  stomach  contents  exercise  an 
unfavourable  influence  upon  the  intestines.  In  the  latter  case,  how- 
ever, the  retention  of  stomach  contents  in  itself  constitutes  an 
indication  for  gastric  lavage.  Lavage  may  be  advisable,  though  not 
necessary,  in  patients  in  whom  an  excessive  production  of  acid  or 
of  mucus  in  the  stomach  causes  an  irritation  of  the  mucous  mem- 
brane of  the  small  intestine,  and  frequently  a  resulting  diarrhoea. 

In  general,  lavage  of  the  stomach  is  done  for  stenosis  or  stricture 
of  the  small  intestine  ;  but  in  obstruction  or  occlusion  of  the  large 
intestine,  according  to  numerous  writers,  it  is  often  a  life-saving  pro- 
cedure. The  credit  for  having  first  tried  and  recommended  gastric 
lavage  in  obstruction  must  be  given  to  Kussmaul  and  his  disciple 
Calm*.  From  the  observation  of  three  cases,  they  showed  that  by 
means  of  this  procedure  cases  of  ileus  with  a  bad  prognosis  could 
sometimes  be  cured.  Soon  after  Senator- Hasenclever ^,  Küster^, 
Henoch '',  Ewald  ^,  Kauffmann^,  Kuhn^*',  Curschmann^,  Pollak^^ 
and  others  reported  successful  cases,  and  at  the  present  time  we 
are  justified  in  considering  gastric  lavage  as  a  useful  procedure, 
scarcely  less  important  than  opium. 

As  Nothnagel  ^^  quite  properly  observes,  we  must  not  expect  too 
much  from  gastric  lavage  ;  indeed,  that  procedure  at  times  may  not 
only  be  ineffectual,  but  even  harmful,  since  it  can  further  diminish 
the  already  exhausted  strength  of  the  patients.  The  results  from 
lavage  would  depend  upon  the  nature  of  the  obstruction  and  our 
ability  or  inability  to  overcome  it  by  diminishing  the  pressure 
above.  Since  the  nature  of  the  obstruction  in  acute  cases  can 
usually  not  be  determined,  it  can  be  readily  understood  that  gastric 
lavage  may  be  a  life-saving  procedure  in  one  case,  while  in  another 
case  its  effect  will  be  an  entirely  negative  one. 

One  point,  however,  shoul'd  always  be  borne  in  mind  :  Gastric 
lavage  should  always  be  resorted  to  in  the  early  stages  of  ileus. 
The  more  violent  and  f  secal  the  vomiting,  the  greater  the  indication 
for  gastric  lavage.  For  we  recognise  in  fsecal  or  feculent  vomiting 
a  certain  sign  of  a  marked  putrefaction  of  the  stagnating  contents 
above  the  site  of  strangulation,  and  only  through  the  relief  of  this 
condition  can  we  check  the  violent  peristalsis  of  the  bowel  and  the 
stagnation  of  its  contents.     As  a  rule,  therefore,  lavage  is  only  in- 


184  DISEASES  OP   THE  INTESTINES 

dicated  in  those  cases  of  ileus  wliicli  have  not  progressed  for  more 
than  twentj-four  to  forty-eight  hours.  In  exceptional  cases,  the 
period  when  the  general  condition  of  the  patient  is  a  good  one, 
lavage  may  be  tried  at  a  later  period  of  the  affection.  Where  there 
is  already  beginning  heart  failure,  a  miserable,  rapid  pulse,  and 
possibly,  too,  impending  death,  the  chances  of  accomplishing  any 
benefit  whatever  with  the  procedure  are  very  slim  indeed.  If  a  case 
such,  as  that  of  Pollak  *  is  now  and  then  reiDorted,  in  which,  under 
most  desperate  conditions,  a  cure  was  effected,  it  only  demonstrates 
the  utmost  extreme  in  which  lavage  may  be  of  benefit.  In  private 
practice  it  is  not  always  easy  to  resist  the  urgent  wishes  of  those 
interested  in  the  patient,  who  want  every  measure  tried  w^hich  can 
possibly  save  the  patient,  particularly  if  nothing  can  be  lost  and 
possibly  much  gained  thereby.  It  will  always  be  well,  however, 
to  point  out  the  fact  that  such  a  mechanical  procedure  in  the  late 
stage  of  the  affection  may  hasten  the  fatal  termination  of  the  case. 

The  condition  which  presents  itself  in  chronic  stenoses,  and  the 
indication  for  its  relief,  is  much  simpler.  Of  these  stenoses,  those  of 
the  small  intestine,  particularly  of  the  duodenum  (supra-  and  infra- 
papiEary),  call  for  washing  out  of  the  stomach.  The  conditions  are 
so  much  like  those  of  stenoses  of  the  pylorus  that  they  are  to  be 
treated  just  like  the  latter.  We  must  not  wait,  therefore,  wdth 
lavage  until  vomiting  becomes  incessant,  but  should  begin  as  soon 
as  the  stomach  contents  give  evidence  of  stasis  (in  infrapapillary 
stenosis,  bile-stained  or  feculent). 

It  is  quite  evident,  however,  that  only  in  rare  cases  can  we  secure 
permanent  relief  of  the  stenosis  by  lavage. 

Technic  of  Gastric  Lavage  ik  Intestinal  Obstruction  and 

Stenosis 

This  differs  in  a  few  points  from  ordinary  methods  of  lavage. 
In  the  first  place,  the  stomach  must  be  washed  out  several  times 
daily  (two  to  five),  and  the  washing  must  be  continued  each  time 
until  the  stomach  is  entirely  empty.  The  succeeding  lavage  must 
not  be  delayed  until  vomiting  again  occurs,  but  must  be  done  as 
soon  as  fsecal  matter  again  enters  the  stomach.  This  will  be  shown 
by  renewed  distention  of  the  stomach,  which  has  become  less  promi- 
nent immediately  after  the  former  lavage.  The  fact  that  only  clear 
water  flows  away  with  the  first  washing  must  not  deter  us  from  fur- 

*  Loc.  cit.  (Case  IV). 


INJECTIONS  185 

ther  lavage,  particularly  where  the  patient  lias  previously  vomited 
large  quantities.  I  usually  give  a  centigram  of  morphin  subcutane- 
ously  before  washing  out  the  stomach,  I  have  never  had  occasion 
to  cocainize  the  pharynx.  A  hypodermic  injection  of  caffein  or 
camphor  may  be  necessary  previous  to  the  lavage.  Skilful  technic 
(compression  of  the  tube  upon  its  withdrawal  (Ewald) )  will  enable 
us  always  to  avoid  aspiration.  The  pulse  is  to  be  carefully  watched 
in  very  weak  individuals.  The  technic  of  gastric  lavage  in  chronic 
stenoses  differs  in  no  wise  from  that  of  stenoses  of  the  pylorus. 
Here,  too,  once  a  day,  best  in  the  morning,  is  sufficient ;  or  in  the 
evening,  where  rest  is  disturbed  by  the  decomj)Osition  of  the  stag- 
nating products. 

LITERATURE 

1.  Penzoldt.     In  Penzoldt-Stintzing's  Handbuch,  Bd.  iv,  S.  520. 

2.  Fleiner.     Berliner  klin.  Wochenschr.,  1893,  No.  3  u.  4. 

3.  Curschmann.     Deutsche  med.  Wochenschr.,   1887,   No.  21,   and  Verhand- 

lungen d.  VIII.  Congr.  f.  innere  Medicin,  1889.    (Compare  the  instructive 
discussion  recorded  there.) 

4.  Cahn.     Berliner  klin.  Wochenschr.,  1884,  S.  669. 

5.  Hasenclever.     Berliner  klin.  Wochenschr.,  1885,  S.  65. 

6.  Küster.     Ibid.,  1885,  No.  27  u.  28. 

7.  Henoch.     Ibid. 

8.  Ewald.     Ibid. 

9.  Kauffmann.     Vereinsbl.  der  Pfälzer  Aerzte,  iii,  S.  185. 

10.  Kuhn.     Bulletin  general  de  Therapeutique,  1885,  15  Juliet. 

11.  8.  Pollak.     Wiener  med.  Wochenschr.,  1892,  No.  51,  and  1893,  No.  1  u.  f. 

12.  Nothnagel.     Die  Erkrankungen  des  Darms  u.  Peritoneum,  S.  406. 


CHAPTEK    XII 

MEDICINAL   TREATMENT  OF  INTESTINAL  DISEASES 

1 .    Cathartics 

By  cathartics  we  understand  those  remedies  which  are  capable  of 
ridding  the  intestines  of  their  contents  within  a  short  time.  Since 
earhest  times  these  have  been  divided  into  mild  {eccoprotica  sive 
lenitiva)  and  powerful  cathartics  {drastica).  Between  these  classes 
there  is  a  middle  class,  the  so-called  neutral  salts,  which  belong  to 
one  or  the  other  classes  according  to  dosage  employed  and  the  indi- 
vidual effect  obtained. 

In  spite  of  numerous  investigations  (confined  for  the  most  part, 
however,  to  animals),  our  knowledge  of  the  action  of  cathartics  is 
very  limited.  The  effect  of  an  individual  cathartic  varies  in  all 
probability  with  its  chemical  state.  This  accounts  for  the  variety 
of  action  observed.  Thus  castor  oil  acts  only  after  emulsification 
by  the  pancreatic  juice  and  the  bile ;  gamboge,  elaterium,  jalap,  and 
scammony  act  similarly. 

Calomel  is  changed  in  the  small  intestines ;  a  portion  of  it  is 
converted  into  corrosive  sublimate.  "We  do  not  know  in  what  man- 
ner this  substance  acts ;  all  mercurial  salts  cause  increased  catharsis. 
It  is  probable  that  the  action  of  this  drug  begins  in  the  upper  part 
of  the  intestines,  while  other  cathartics,  such  as  senna,  aloes,  and 
colocynth,  exert  their  main  action  upon  the  large  intestine  (Nasse, 
Radziejewski). 

The  action  of  the  neutral  salts  appeared  easiest  of  explanation. 
It  was  natural  to  suppose  that  their  action  was  due  to  a  transuda- 
tion. As  great  an  authority  as  Liebig  supported  this  theorj^ ;  he 
was  followed  by  French  investigators,  chief  among  whom  was  Pois- 
seuille.  Later  Aubert  ^  opposed  this  theory,  while  Moreau  ^  advo- 
cated it.  Eadziejewski  ^  regards  the  influence  upon  peristalsis  as 
the  main  principle  in  the  action  of  cathartics.  Brieger^  showed 
that  the  action  of  laxatives  is  due  to  stimulation  of  peristalsis  ;  neu- 
tral salts  in  addition  cause  an  increased  secretion  of  water  and  a 
larger  secretion  from  the  glands  of  the  intestinal  mucous  membrane; 
186 


MEDICINAL   TREATMENT  OP  INTESTINAL  "DISEASES        187 

finally,  that  drastic  cathartics  in  small  doses  act  like  laxatives,  while 
in  larger  doses  they  cause  an  inflammatory  exudate  and  a  hyper- 
secretion. 

These  unsatisfactory  results  include  all  that  we  know  of  the 
theory  of  the  action  of  cathartics,  and  we  must  therefore  place  our 
dependence  upon  experience  gained  in  daily  practice. 

In  this  connection  my  experience  leads  me  to  emphasize  that 
every  cathartic,  or  group  of  cathartics,  has  clinically  a  distinct  action, 
and  therefore  distinct  indications.  For  example,  in  acute  constipa- 
tion, castor  oil,  which  acts  rapidly  and  painlessly,  is  first  to  be  con- 
sidered ;  in  acute  indigestion,  with  or  without  bacteriological  basis, 
calomel  in  large,  rapidly  repeated  doses  is  useful.  The  use  of  the 
neutral  salts  or  bitter  waters  is  indicated  in  bilious  individuals  with 
hemorrhoids.  Between  these  two  are  a  whole  series  of  other  cathar- 
tics whose  use  is  not  especially  indicated,  but  which  are  valuable 
only  when  varied,  since  most  of  them  lose  their  action  after  a  time. 
The  physician  should,  however,  have  a  knowledge  of  the  main 
and  secondary  action  of  these  remedies,  and  make  his  own  indi- 
cations. 

Opium  and  belladonna  occupy  a  special  position  among  cathar- 
tics. We  shall  recur  later  to  the  effect  of  these  substances  upon 
the  intestines.  In  this  connection  it  need  only  be  mentioned  that 
they  should  be  used  where  spastic  contraction  prevents  the  intes- 
tine from  emptying  itself.  Lead  colic  is  a  typical  example  of  this. 
In  spastic  affections  of  the  intestine,  flatulent  colic,  stenosis  of  the 
intestines,  and  in  ileus,  one  can  accomplish  more  by  overcoming 
the  spasmodic  contraction  of  the  bowels  than  by  the  use  of  cathar- 
tics themselves. 

A  large  number  of  cathartics,  once  very  much  in  favour,  have 
now  become  obsolete.  Among  these  substances  we  may  mention 
agaricus,  euphorbium,  fructus  colocynthidis,  gamboge,  hellebore, 
herba  gratiolss,  leptandra  virginica,  metallic  mercury,  elaterium, 
croton  oil,  scammonium,  and  jalap  tubers.  A  number  of  other 
remedies  might  with  justice  meet  with  the  same  fate.  The  follow- 
ing, on  the  contrary,  are  recommended  if  used  under  proper  indica- 
tions :  castor  oil,  olive  oil,  calomel,  magnesium  salts,  cascara  sagrada, 
rhubarb  preparations,  tamarinds,  podophyllin,  precipitated  sulphur, 
tartrate  of  soda,  frangula  bark,  senna  leaves. 

With  the  exception  of  glycerin,  subcutaneous  and  rectal  admin- 
istration of  cathartics  (aloes,  etc.)  has  heretofore  been  but  little 
employed  in  medicine,  although  the  subcutaneous  employment  of 


188  DISEASES  OP  THE  INTESTINES 

physostigma  for  cathartic   purposes  lias   been  well  established  in 
veterinary  practice. 

Indications  foe  the  Use  of  Cathaetics 

We  must  here  differentiate  between  acute  and  chronic  (habitual) 
constipation.  The  employment  of  cathartics  in  the  first-named 
condition  will  depend  principally  upon  the  cause  of  the  consti- 
pation— acute  gastric  catarrh,  initial  stage  of  acute  infectious  dis- 
eases, acute  intestinal  obstruction,  typhlitis,  appendicitis,  invagina- 
tions, etc. 

The  employment  of  cathartics  is  indicated  only  where  we  can 
exclude  inflammatory  processes  and  displacements  of  the  intestines. 
As  long  as  there  is  any  doubt,  and  there  is  no  indication  for  active 
treatment  of  the  acute  constipation,  one  should  limit  himself  to 
enemata,  which  can  never  do  much  harm.  When  there  is  a  neces- 
sity for  cathartics  in  acute  constipation,  a  rapidly  acting  and  certain 
cathartic  should  be  used.  If  there  are  many  stomach  symptoms, 
calomel  is  to  be  recommended  ;  where  there  are  none  such,  castor 
oil  is  preferable.  The  various  rhubarb  preparations  are  valuable, 
but  these  lack  the  thorough  action  of  the  cathartics  just  named. 
No  others  need  be  considered  in  these  cases. 

In  treating  these  conditions  it  should  be  remembered  that  cathar- 
tics should  be  stopped  as  soon  as  possible  ;  it  is  therefore  advisable 
not  to  give  too  small  doses.  If  after  one  or  more  doses  the  con- 
stipation recurs  (Avhich  is  frequently  the  case),  it  is  advisable  to 
treat  the  patient  according  to  the  principles  previously  laid  down — 
i.  e.,  by  dietetic  measures. 

In  chronic  {hahitual)  constipation  the  indication  for  the  use  of 
a  cathartic,  and  the  selection  of  the  one  to  be  used,  depend  upon 
the  nature  of  the  affection.  We  must  distinguish  between  condi- 
tions in  whicli  the  patency  of  the  intestinal  canal  is  diminished, 
whatever  be  the  situation  or  the  cause,  and  those  in  which  the  lumen 
of  the  bowel  is  unobstructed. 

In  the  former  class  of  cases,  especially  in  stenoses  of  the  intes- 
tine, cathartics  are  generally  indispensable  and  symptomatically 
useful.  Since  a  stasis  of  fsecal  contents  which  is  favourable  to 
decomposition  processes  develops  above  the  point  of  stenosis,  cathar- 
tics are  preferable  to  enemata,  even  when  stenosis  is  situated  low 
down.     Enemata  are  generally  without  result. 

The  kind  of  cathartics  to  be  used  is  a  question  of  great  impor- 
tance ;  those  only  should  be  selected  which  do  not  cause  painful 


MEDICINAL  TREATMENT  OF  INTESTINAL   DISEASES        189 

spasmodic  contraction  and  thus  create  a  danger  of  perforation. 
These  are  the  mildly  acting  preparations  of  rhubarb,  compound 
licorice  powder,  magnesia  usta,  sodium  phosphate,  preparations  of 
tamarind  and  cascara  sagrada,  tea  of  frangula  bark,  etc.  Prepara- 
tions of  aloes,  bitter  waters,  podopliyllin,  and  the  senna  preparations 
are  to  be  used  with  caution. 

In  the  second  class  of  cases— i.  e.,  those  in  whicli  the  permea- 
bility of  the  bowel  is  preserved — the  character  of  the  disease  deter- 
mines the  method  of  treatment  to  be  pursued.  In  my  opinion 
cathartics  should  be  used  only  in  desperate  cases  of  constipation, 
and  in  old  people  in  whom  the  normal  reflex  excitability  of  the 
intestinal  muscle  has  disappeared.  Here  one  should  endeavour  to 
use  small  doses  of  the  milder  aperients.  Aided  by  a  stimulation  of 
intestinal  activity  by  proper  diet,  this  procedure  will  often,  though 
not  always,  be  successful. 

The  habitual  use  of  cathartics  in  young  persons  is  to  he 
avoided.  After  a  misuse  of  these  for  years,  it  is  very  difficult  to 
succeed  in  bringing  back  normal  peristalsis.  I  have  already  men- 
tioned (page  149)  that  even  in  such  cases  one  can  sometimes  obtain 
good  results. 

CONTKA-INDICATIONS    TO   THE    UsE    OF    CaTHAETICS 

In  acute  affections,  in  which  the  diagnosis  of  occlusion  of  the 
intestine  is  certain,  the  use  of  cathartics  is  contra-indicated.  In 
the  early  stages  of  an  acute  intestinal  affection,  which  later  proves 
to  be  a  case  of  intestinal  obstruction,  one  can  not  blame  the  physi- 
cian for  having  given  a  cathartic.  In  the  later  stages,  where  the 
symptoms  of  intestinal  obstruction  are  clear,  it  is  an  error  to  give  a 
cathartic.  The  same  holds  true  for  acute  inflammatory  affections 
of  the  type  of  an  appendicitis.  Our  present  knowledge  of  the 
nature  of  this  disease  (appendicitis)  allows  us  to  diagnosticate  a 
typhlitis  stercoralis  in  exceptional  cases  only,  so  that  it  is  always 
advisable  to  keep  in  mind  the  possibility  of  a  primary  disease  of 
the  vermiform  appendix.  If,  notwithstanding,  there  is  reason  for 
emptying  the  bowel,  enemata  are  indicated  (see  page  180).  When, 
in  exceptional  cases,  there  is  a  particular  reason  for  one  dose  of  a 
cathartic,  castor  oil  is  by  all  means  the  surest  and  best  drug  to 
use.  It  is  far  preferable  to  the  saline  cathartics,  bitter  waters, 
or  rhubarb.  In  this  connection  we  must  mention  that  cathartics 
are  also  contra-indicated  in  the  habitual  constipation  which  so  fre- 
quently follows  appendicitis.     In  most  cases  the  patients  do  well 


190  DISEASES  OF  THE  INTESTINES 

with  proper  feeding,  or  good  results  may  be  obtained  from  enemata, 
glycerin  suppositories,  etc. 

Cathartics  are  contra-indicated  in  young  people  who  have 
been  constipated  for  a  short  time  only.  In  children  cathartics 
are  absolutely  contra-indicated,  and  their  employment  can  not  be 
too  strongly  condemned.  In  these  cases  continued  and  energetic 
care  in  feeding,  combined,  perhaps,  with  massage  and  gymnastics, 
gives  good  results.  One  should  try  dietetic  measures  for  several 
weeks  before  resorting  to  the  constant  employment  of  cathartics. 
These  drugs  are  contra-indicated  in  chronic  gastric  and  intesti- 
nal catarrhs.  As  regards  the  former,  I  have  gained  the  .impres- 
sion that  cathartics  have  an  unfavourable  influence  upon  the 
secretion  of  the  gastric  juice.  This  seems  to  me  to  be  the 
reason  why  we  more  frequently  meet  with  insufficiency  of  gastric 
secretion  in  women  than  in  men,  though  the  latter  are  more  apt 
to  acquire  gastric  affections  on  account  of  their  use  of  alcohol  and 
nicotin. 

Still  more  important  is  the  contra-indication  to  the  continued 
use  of  purgatives  in  chronic  enteritis,  affecting  either  the  small  or 
the  large  intestines.  A  careful  observer  who  is  accustomed  to 
make  frequent  examinations  of  the  fgeces  will  doubtlessly  have 
recognised  that  a  slight  enteritis  of  short  duration,  unnoticed  by 
the  patient,  results  not  only  from  continual  use  of  cathartics,  but 
may  also  follow  one  or  two  doses  of  a  mild  laxative.  This  is  much 
more  marked  where  drastic  cathartics  are  habitually  emplo^yed,  and 
I  feel  I  am  not  exaggerating  when  I  maintain  that  the  more  fre- 
quent occurrence  of  membranous  enteritis  in  women  is  due  to  care- 
less employment  of  laxatives.  This  is  already  shown  from  the 
fact  that  the  mucous  secretion  ceases  at  once,  and  in  most  cases 
permanently,  when  intestinal  functions  are  regulated  by  physio- 
logical laxatives.  In  the  special  part  of  this  work  I  shall  illustrate 
this  by  a  series  of  histories.^ 

2.    Antidiarrhoeal  Remedies 

Since  earliest  times  medicinal  remedies  have  played  an  important 
role  in  the  treatment  of  chronic  diarrhoea.  They  are  believed  either 
to  inhibit  peristaltic  action,  thereby  creating  better  conditions  for 

*  von  Noorden,  in  a  very  remarkable  article  upon  membranous  enteritis  (Zeit- 
sehr.  für  prakt.  Aerzte,  1898,  No.  1)  takes  a  stand  which  I  maintained  a  number  of 
years  ago  (cf.  Deutsch,  med.  Wochenschr.,  1883,  S.  1000). 


MEDICINAL  TREATMENT  OP  INTESTINAL  DISEASES        191 

the  absorption  of  nutritive  material  from  the  intestinal  canal,  or 
restrict  the  production  of  intestinal  secretion,  or  finally  to  cause 
neutralization  of  certain  fermentative  processes  in  the  intestines. 
Antidiarrhoeal  drugs  are  furthermore  employed  to  furnish  a  pro- 
tective covering  for  intestinal  ulcers,  in  so  far  as  these  are  the  cause 
of  the  diarrhoea  and  thereby  to  exert  a  curative  effect  upon  the 
latter.  Some  remedies  (calomel,  tincture  of  rhubarb,  belladonna, 
etc.)  are  laxative  in  large  doses  but  binding  in  small  ones.  There 
are  some  drugs,  too,  which  exert  a  beneficial  influence  in  diarrhcea 
without  our  being  able  to  explain  their  action. 

The  correctness  of  the  above  statement  of  the  action  of  drugs 
in  diarrhoea  may  be  disputed ;  certain  it  is,  however,  that  acute  and 
chronic  diarrhoea  frequently  are  cured  when  drugs  are  administered. 

1.  Kemedies  which  inhibit  peristalsis  : 

These  include  opium  and  its  alkaloids  (morphin,  codein,  nar- 
cein,  and  papaverin),  as  well  as  atropin  and  the  belladonna  prepara- 
tions (particularly  in  small  doses). 

2.  Remedies  which  act  upon  the  intestinal  mucous  membrane 
(astringents) : 

These  include  tannic  acid  (tannin)  and  its  preparations,  tannigen 
(diacetyl  tannic  acid)  and  tannalbin  (tannin  albuminate).  Among 
other  remedies  which  contain  tannic  acid  may  be  mentioned  Colombo, 
catechu,  hsematoxylon,  cascarilla,  ratania,  oak  bark,  cotoin,  and 
paracotoin.  Nitrate  of  silver  should  also  be  classed  with  the  intes- 
tinal astringents. 

3.  The  antifermentative  remedies  include  calomel,  salicylate  of 
bismuth  and  beta-naphthol  bismuth  (orphol),  nosophen,  paraform, 
tannoform,  creosote,  salol,  beta-naphthol,  etc. 

4.  The  remedies  which  furnish  a  protective  coating  include 
carbonate  and  phosphate  of  calcium  and  similar  chalk  preparations 
(pulvis  cretse,  talcum  pi-eparations,  bismuth,  etc.). 

The  Indications  foe  and  Use  of  Antidiaeehceal  Remedies 

Antidiarrhoeal  remedies  are  administered  by  mouth  or  as  sup- 
positories (opium,  morphin,  belladonna,  etc.),  or  finally  as  rectal 
injections.  Only  rarely  are  they  given  subcutaneously.  For  rectal 
injection,  tannin,  nitrate  of  silver,  aluminium  (preferably  the  aceto- 
tartrate  salt)  or  boracic  acid  are  best.  They  are  useful  in  diseases 
of  the  large  intestine  only,  while  the  internal  remedies  are  to  be 
used  in  catarrhs  of  all  parts  of  the  bowel. 

In  some  cases  it  is  easy  to  determine  which  remedy  to  employ ; 


192  DISEASES  OF  THE  INTESTINES 

in  others  the  difficulty  of  correctly  interpreting  the  action  of  the 
remedies  makes  the  selection  of  the  proper  one  in  a  given  case 
less  easy. 

Thus  the  use  of  antidiarrhoeal  remedies  is  clearly  indicated  in 
acute  affections  following  exposure  or  errors  in  diet.  The  question 
arises  in  these  cases :  Should  the  remedy  he  given  at  once,  or  only 
after  the  bowels  have  been  sufficiently  emptied  ?  In  weak  individ- 
uals the  immediate  administration  is  in  general  the  better  proce- 
dure ;  but  where  the  general  condition  is  very  good,  we  should  not 
be  too  eager  to  check  a  diarrhoea,  particularly  if  this  be  accompanied 
by  fever  (beginning  typhoid,  infectious  gastro-enteritis,  etc.),  or  if 
there  be  an  epidemic  of  cholera.  On  the  contrary,  it  is  much  better 
to  keep  up  the  diarrhoea  for  several  days  by  the  administration  of 
calomel — large  doses  at  first,  smaller  ones  later. 

If  none  of  these  complications  be  jDresent,  we  must  give  a 
rapidly  acting  and  certain  astringent  remedy.  Opium  is  the  only 
one  to  be  considered,  and  should  be  given  in  the  form  of  the  tinc- 
ture, the  powder,  or  the  extract,  combined,  perhaps,  with  the  tincture 
or  the  extract  of  belladonna.  All  other  drugs,  as  well  as  any  other 
combination  with  opium,  are  superfluous.  As  a  rule,  it  is  better  to 
give  the  opium  by  the  mouth  than  by  the  rectum  ;  only  where  there 
is  pronounced  nausea  or  marked  tenesmus  should  opium  be  given 
jper  rectum,  and  then  in  the  form  of  suppositories  combined,  perhaps, 
with  belladonna  extract.  Morphin,  codein,  papaverin,  and  other 
alkaloids  of  opium  are  inferior  to  the  mother  drug  in  their  action. 
l^oi  enough  is  known  about  subcutaneous  injections  of  the  watery 
extract  to  allow  one  to  express  an  opinion  as  to  their  efficiency. 

Opium,  whenever  indicated,  should  be  given  in  effective  doses, 
but  continued  for  a  short  time  only.  I  would  strongly  w^arn  against 
small  divided  doses.  The  correct  amount  for  an  adult  is  twenty 
drops  of  the  tincture  two  or  three  times  a  day,  or  two  or  three  doses 
of  the  extract,  each  equal  to  0.05  gram.  With  this  and  proper  feed- 
ing an  acute  intestinal  catarrh  is  generally  cured.  For  eight  to  ten 
days  the  patient  must  be  instructed  in  rules  of  diet  (see  section  on 
Diet).  The  main  use  of  opium  is  in  acute  gastro-enteritis ;  it  is 
not  a  remedy  for  prolonged  employment. 

The  other  drugs  above  mentioned  are  used  in  a  variety  of  ways 
and  combinations  in  subacute  and  chronic  diarrhoeas,  especially  in 
those  affecting  the  small  and  upper  part  of  the  large  intestine.  If 
we  were  to  believe  the  pi'aises  which  have  been  sung  in  medical 
literature  about  these  drugs,  especially  during  the  last  decade,  the 


MEDICINAL  TREATMENT   OF  INTESTINAL  DISEASES        193 

treatment  of  chronic  intestinal  catarrhs,  even  those  of  a  tubercular 
variety,  would  seem  to  be  as  promising  and  simple  as  anything  in  all 
internal  medicine.  The  critical  physician  would  naturally  doubt 
this  statement  if  for  no  other  reason  than  for  the  fact  that  new 
pharmaceutical  remedies  are  being  continually  produced  and  recom- 
mended. 

I  have  not  seen  any  lasting  influence  upon  chronic  diarrhoeas 
from  any  of  the  newer  antidiarrhoeal  remedies.  My  experience  in 
this  respect  has  been  a  large  one.  My  results  in  the  treatment  of 
these  conditions  on  exclusively  or  almost  exclusively  dietetic  prin- 
ciples (about  which  the  most  important  facts  have  already  been 
stated)  have  been  just  as  good  as  when  the  newer  remedies  were 
used.  The  so-called  antiseptic  astringent  remedies  would  be  ideal 
if  they  exerted  an  influence  upon  the  disease  without  simultaneous 
dietetic  treatment,  and  if  they  were  able  to  influence  the  mucous 
membrane  in  such  a  manner  that  the  intestine  would  gradually 
become  able  to  bear  almost  normal  regime  without  difiiculty  and 
without  the  occurrence  of  diarrhoeas.  There  is  no  real  value  in  a 
constipating  action  jper  se  of  drugs. 

It  is  true,  I  believe,  that  we  can  use  antiseptic  or  astringent 
drugs  as  adjuvants  to  our  dietetic  and  hygienic  methods.  The  heal- 
ing of  an  intestinal  catarrh  can  be  accomplished  only  by  long-con- 
tinued care  of  the  intestines  as  has  been  described  above,  and  in 
connection  with  long-continued  absolute  rest  in  bed.  Whoever 
looks  for  impressive  results  will  without  doubt  find  great  satisfaction 
from  modern  antiseptics  and  astringents ;  but  whoever  desires  to 
make  a  permanent  cure  of  a  chronic  diarrhoea  can  not  place  a  very 
high  value  upon  these  remedies. 

The  indication  for  the  application  of  astringent  remedies  per 
rectum  is  limited  to  chronic  catarrhs  of  the  large  intestine.  I 
have  sometimes  seen  favourable  results  from  tannin  and  nitrate  of 
silver,  but  have  obtained  much  better  results  from  aceto  tartrate 
of  aluminium  (one  teaspoonful  to  the  litre  of  water).  It  must  be 
mentioned,  however,  that  astringent  remedies  can  not  only  cure 
catarrhs,  but  may  cause  or  aggravate  them.  Great  care  in  the 
administration  and  close  observation  of  the  reaction  following  such 
astringent  injection  is  imperative.  It  is  advisable  to  follow  an 
enema  of  nitrate  of  silver  by  a  neutralizing  injection  of  salt  solu- 
tion. 


194  DISEASES  OP  THE  INTESTINES 

CONTEA-INDICATIONS   TO   THE    UsE    OF   AnTIDIAEKH(EAL    EeMEDIES 

Above  all,  antidiarrhoeal  remedies  are  contra-indicated  where  the 
apparent  symptoms  are  those  of  diarrhoea,  but  the  real  condition  is 
one  of  constipation.  These  remedies  should  not  be  employed  in 
the  diarrhoea  which  accompanies  intestinal  stenosis.  In  carcinoma 
of  the  rectum  there  are  frequent  apparent  diarrhoeas  which  must  be 
considered  as  decomposition  products  of  stagnating  intestinal  con- 
tents. Cathartic  measures  would  be  indicated  in  such  a  case.  It 
is  also  best  to  administer  them  to  patients  with  alternating  diar- 
rhoea and  constipation.  In  these  it  is  advisable  to  wait  several  days 
before  giving  drugs,  in  order  to  come  to  some  conclusion  as  to  the 
nature  of  the  intestinal  disturbance.  Several  years  ago  I  had  occa- 
sion to  observe  a  case  in  which  the  conditions  were  so  complicated 
that  careful  observation  for  several  weeks  was  necessary  before  it 
could  be  determined  that  the  patient  had  chronic  constipation,  and 
not  chronic  diarrhoea.  The  patient,  who  was  very  ill,  was  cured 
when  the  constipation  was  overcome.  Among  the  remedies  contra- 
indicated  in  chronic  diarrhoea,  opium  and  calomel  should  be  men- 
tioned, as  they  are  frequently  wrongly  used.  Although  I  place  a 
high  value  upon  opium  as  a  remedy  in  many  diarrhoeas,  I  always 
hesitate  before  using  it  in  the  chronic  form.  It  is  true,  one  gains 
the  advantage  of  placing  the  bowels  at  rest  for  a  short  time,  but 
meanwhile  they  become  filled  with  putrefying  decomposed  material, 
which  only  reproduces  a  severer  diarrhoea  as  soon  as  the  opium 
effect  has  passed  off.  I  allow  the  use  of  opium  preparations  as  a 
palliative  method  only  during  travel,  in  society,  etc.,  but  even  then 
with  the  greatest  reserve.  I  need  hardly  mention  that  when  there 
is  a  suspicion  of  ulcerations  of  the  intestines  calomel  must  not  be 
used,  or,  if  so,  only  under  restrictions. 

3.    Sedative  Remedies 

Owing  to  the  great  importance  of  these  in  the  therapeutics  of 
intestinal  affections,  it  is  necessary  to  dwell  briefly,  upon  their 
significance  and  use.  They  include  mainly  opium  and  its  principal 
alkaloid,  morphin  (which  in  this  respect  is  superior  to  codein, 
papaverin,  narcein,  etc.),  and  belladonna  with  its  alkaloid,  atropin. 

From  experimental  investigations  very  little  has  been  learned 
regarding  the  manner  in  which  opium  and  its  alkaloids  act.  l^oth- 
nagel's^  opinion  that  the  intestinal  paralysis  results  from  stimulation 


MEDICINAL  TREATMENT  OF  INTESTINAL  DISEASES        195 

of  the  inhibitory  fibres  of  the  splanchnic  is  directly  opposed  to  that 
of  Jacob]  ^  and  Pohl ''',  who,  after  extensive  researches,  have  come 
to  the  conclusion  that  the  paralyzing  effect  of  opium  is  brought 
about  by  diminished  excitability  of  the  intestinal  wall.  The  latest 
investigations  of  Z.  von  Yamossy^  tend  to  show  that  there  is  a 
benumbing  of  the  brain  centres  which  prevents  transference  in  the 
brain  of  centripetal  impulses  of  the  pneumogastric  to  those  centrif- 
ugal nerve  paths  that  control  intestinal  movements. 

We  can  not  here  give  more  than  this  brief  reference.  It  shows 
sufficiently  well,  however,  that  we  still  have  had  no  satisfactory 
explanation  of  the  action  of  opium. 

As  regards  belladonna  and  atropin,  it  is  assumed  that  they  cause 
paralyses  of  the  intestinal  wall,  and  thus  relieve  abnormal  contrac- 
tions of  the  intestinal  coils. 

We  know  more,  however,  about  the  clinical  application  of  nar- 
cotics. The  following  are  the  indications  for  their  use :  To  allay 
inflammation,  to  relieve  painful  contractions,  to  arrest  increased 
intestinal  peristalsis  accompanied  by  profuse  evacuations  of  contents, 
and,  finally,  to  secure  rest  of  the  entire  intestines,  so  as  to  permit  of 
a  correction  of  intestinal  knottings,  invaginations,  incarcerations,  and 
volvuli. 

Appendicitis  furnishes  the  best  example  for  the  use  of  opium  in 
inflammatory  processes.  We  should,  however,  make  a  careful  dis- 
tinction between  the  various  stages  of  this  affection.  In  appendi- 
citis, opium  is  only  indicated  when  symptoms  of  irritation,  fever, 
pain,  and  meteorism  are  present,  and  the  patient's  condition  is  still 
satisfactory.  If  these  symptoms  disappear  after  repeated  large 
doses  of  opium  (e.  g.,  tinct.  opii  gtt.  xx  every  three  hours,  or  extr. 
opii  0.03  gm.  t.  i.  d.),  its  further  use,  though  not  harmful,  is  no 
longer  necessary.  If  the  opium  is  continued  the  dosage  should  be 
reduced  one  half.  If  symptoms  of  irritation  have  been  present  for 
three  or  four  days,  opium  is  contra-indicated,  for  then  there  de- 
velop intestinal  paralyses,  which  are  overcome  only  with  the  great- 
est difficulty. 

If  symptoms  of  irritation  continue  and  those  of  collapse  (rapid, 
compressible  pulse,  general  depression,  etc.)  begin  to  appear,  opium 
must  at  once  be  stopped.  This  is  the  stage  in  which  opium,  as  sur- 
geons very  correctly  claim,  masks  the  disease  and  gives  rise  to  false 
hopes. 

A  similar  rule  applies  to  acute  intestinal  occlusions.  Here  also 
opium  is  indicated  in  the  early  stage  with  symptoms  of  reaction. 


196  DISEASES  OF  THE  INTESTINES 

If  opium  does  not  then  yield  the  desired  results,  a  curative  action 
can  no  longer  be  expected  from  it ;  it  can  only  induce  euthanasia. 
The  same  objections  against  the  giving  of  large  doses  apply  as  in 
appendicitis,  undoubtedly  large  doses  of  opium  temporarily  relieve 
the  seriousness  of  the  condition,  but  actual  benefit  can  no  more  be 
expected  than  from  an  infusion  of  digitahs  in  a  cardiac  case  with 
impending  paralysis.  The  pulse  and  general  condition  should  guide 
us  in  the  management  of  acute  intestinal  obstruction.  If  these  are 
good  and  the  features  "  composed  "  (von  Leyden),  opiates  will  at  least 
do  no  harm ;  if  these  are  not  good,  then  opium  can  only  help  seal 
the  patient's  fate. 

A  few  words  regarding  the  treatment  of  enteralgias,  intestinal 
colic,  peristaltic  restlessness,  and  acute  diarrhceas.  Whatever  may 
be  the  etiology  of  these  conditions,  narcotics  will  always  be  of  bene- 
fit, for  they  quiet  the  excessive  peristalsis,  relieve  pain,  and  thus 
enable  solid  contents  to  pass  through  the  intestinal  canal,  and  fiuid 
contents  to  become  more  solid. 

In  a  given  case  it  is  by  no  means  immaterial  whether  we  admin- 
ister opium  or  one  of  its  alkaloids  (particularly  morphin)  or  bella- 
donna (or  atropin).  This  has  been  sufficiently  shown  by  clinical 
experience.  Opium  is  far  superior  to  any  of  its  alkaloids  in  quiet- 
ing the  intestines  or  in  arresting  peristalsis.  Morphin  has  only  the 
analgesic  property  of  opium.  In  any  case  in  which  we  desire  a 
sedative  effect  upon  the  intestines,  as  well  as  a  slowing  or  an  arrest 
of  peristalsis,  opium  will  be  found  superior  to  all  other  narcotics. 

On  the  other  hand,  extract  of  belladonna  in  doses  of  0.01  to 
0.03  gram,  and  its  alkaloid,  atropin,  in  doses  of  from  0.005  to  0.001 
gram,  are  indicated  in  all  colicky  and  painful  crises.  Like  the  opi- 
ates, they  may  in  such  cases  even  have  a  laxative  action.  In  gen- 
eral, their  action  is  weaker  than  that  of  the  opiates  ;  their  long-con- 
tinued employment  is  always  attended  by  danger  of  poisoning. 
Opiates  are  frequently  combined  with  belladonna. 

4.  Remedies  for  Flatulence 

Since  early  times  a  large  number  of  remedies  have  had  the 
reputation  of  allaying  flatulency,  either  through  combination  with 
the  gases  or  excitation  of  the  intestinal  motility,  or  through 
other  unknown  ways.  As  regards  the  power  to  combine  with 
gases,  the  magnesia  salts,  especially  magnesia  usta,  play  an  impor- 
tant part.     It  is  well  known  that  outside  of  the  body  magnesia  usta 


MEDICINAL  TREATMENT   OF  INTESTINAL  DISEASES        197 

can  absorb  a  large  quantity  of  carbonic-acid  gas  (1  gram  absorbs 
about  1,100  cubic  centimetres).  To  what  extent  this  substance  can 
absorb  gas  in  the  gastro-intestinal  canal  is  still  a  matter  of  ques- 
tion. In  the  stomach,  magnesium  chlorid  is  formed  by  combina- 
tion with  hydrochloric  acid  ;  in  the  intestines  only  the  residue  of  the 
magnesia  usta  can  be  converted  into  magnesium  carbonate.  It  is 
very  probable,  too,  that  this  formation  of  carbonate  of  magnesia 
does  occur  in  the  intestinal  canal,  for,  after  the  ingestion  of  mag- 
nesia, patients  frequently  have  borborygmi  and  expel  much  gas.  To 
a  certain  extent,  however,  the  laxative  action  of  the  magnesia  may 
cause  such  symptoms. 

The  second  group  of  remedies — i.  e.,  those  which  excite  intes- 
tinal motility — is  said  to  act  by  increasing  the  muscle  tone.  It 
includes  nux  vomica  and  its  preparations  (the  tincture,  the  fluid 
extract,  and  its  alkaloid,  strychnin),  as  well  as  extract  of  physo- 
stigma.    We  will  speak  of  these  more  in  detail  in  the  next  division. 

Yery  little  is  known  of  the  action  of  the  so-called  carminatives. 
But  here,  as  everywhere  in  science,  experience  is  the  best  guide, 
and  it  has  shown  us  that  in  flatulency  very  great  benefit  is  often 
derived  from  the  use  of  carminatives. 

The  carminative  remedies  include  various  so-called  carmina- 
tive teas,  such  as  valerian,  fennel,  peppermint,  caraway,  anise, 
thyme,  and  the  oils  obtained  from  these  substances,  the  most  fre- 
quently employed  being  oils  of  menthol,  caraway,  and  fennel.  These 
remedies  very  probably  have  mild  antiseptic  properties,  such  as  the 
oil  of  menthol  has  been  shown  to  possess.  Based  on  this  antiseptic 
property,  menthol  (0.1  to  0.2  in  gelatin  capsules)  has  been  recom- 
mended for  the  relief  of  flatulency.*  The  following  sums  up  the 
latest  ideas  regarding  the  relative  value  of  the  various  preparations. 
With  teas  made  from  the  fruit  or  leaves  there  is  the  additional 
effect  derived  from  the  heat.  We  know  from  experience  that 
heat  when  applied  externally,  or  hot  solutions  taken  internally, 
exert  a  beneficial  action  on  acute  colic  and  flatulency.  The  oleo- 
saccharates  and  the  oils  are  more  in  place  in  the  chronic  forms 
of  flatulency.  The  oils  are  to  be  given  singly  or  combined,  in 
doses  of  3  to  5  drops  thrice  daily,  and  the  oleosaccharates  in 
amounts  varying  from  very  minute  quantities  to  a  teaspoonf ul,  also 
thrice  daily.     The  combination  of  magnesia  usta  with  the  so-called 

*  To  insure  solution  it  is  necessary  to  drink  an  alcoholic  mixture  (cognac  or 
wine)  after  the  dose  is  taken, 
14 


]^98  DISEASES  OP   THE  INTESTINES 

oleosacchai-ates   is  very  effectual  where   constipation  exists.     For 
example  : 

j^  Magn.  ustse 15.0 

Olseosaccli.  menthae 5.0 

M.     Pulv.     Sig.  :  A  quarter  to  a  teaspoonful  thi-ee  times  a  day. 

In  a  number  of  cases  of  chronic  flatulency,  pulverized  caroway 
fruit  in  tablet  form,  in  doses  of  from  0.5  to  1  gram,  has  proved 
very  serviceable  to  me. 

Charcoal  in  the  form  of  freshly  burnt  animal  or  wood  charcoal 
is  still  very  frequently  given  as  a  gas-absorbing  remedy.  In  France, 
especially,  the  "  pastilles  de  Bellocq,"  which  consist  mainly  of  char- 
coal, are  very  generally  used.  "We  can  hardly  expect  any  benefit 
from  charcoal,  however,  since  it  only  absorbs  gases  while  it  is  in  a 
dry  state. 

5.    Tonic  Remedies 

Are  there  any  remedies  which  may  rightly  be  called  intestinal 
tonics  ?  Concerning  this  subject  httle  has  been  learned  from  ani- 
mal experiments.  Although  there  are  no  exact  indications  for  their 
use,  and  no  convincing  results  have  been  obtained,  drugs  are  often 
employed  for  this  purpose.  They  include  the  numerous  bitters 
which,  according  to  the  investigations  made  by  Hamm  ^  and  Kobert, 
stimulate  intestinal  as  well  as  gastric  peristalsis ;  furthermore,  the 
preparations  of  nux  vomica  are  also  given  (tincture  of  nux  vomica, 
gtt.  x-xv,  extract  of  nux  vomica  0.01  to  0.03,  or  nitrate  of  strych- 
nin 0.001  per  dose,  preferably  subcutaneously).  The  other  bitters 
(tinct.  amara,  gentian,  creosote,  etc.)  also  enjoy  considerable  repu- 
tation as  intestinal  tonics.  Besides  these  remedies,  I  have  fre- 
quently obtained  good  results  in  painful  flatulency  from  the  use  of 
the  extract  of  calabar  bean.  Attention  was  first  directed  to  this 
drug  by  Subbotin  ^°,  and  later  by  S.  Schaef er  ^\ 

5.  Extr.  physostigmge 0.05 

Glycerin  ad 10.00 

M.     Sig. :  Ten  drops  three  times  a  day. 

Or  the  same  remedy  may  be  given  in  pill  form  in  doses  of  0.005 
gram.  It  has  no  laxative  action.  I  have  never  seen  any  injurious 
effect  result  from  the  extract  of  calabar  bean,  and  I  am  convinced 
that  in  atony  of  the  intestines  this  drug  is  as  worthy  a  trial  as  nux 
vomica. 


MEDICINAL  TREATMENT   OP  INTESTINAL  DISEASES        199 

6.    Intestinal    Antiseptics 

Owing  to  the  numerous  investigations  of  Bouchard  and  Dujar- 
din-Beaumetz  and  their  scholars,  the  idea  that  it  is  possible  to 
disinfect  the  intestinal  canal  in  fermentative  and  putrefactive  con- 
ditions has  been  widely  accepted,  especially  in  France.  These  inves- 
tigators have  evolved  a  method  of  treatment  which  has  been  named 
"  antisepsie  intestinale."  Although  it  had  many  enthusiastic  fol- 
lowers in  Germany,  this  movement  has  been  reluctantly  taken  up. 
Recently  a  marked  reversal  of  opinion  has  taken  place  in  France  ^^, 
for  the  lack  of  results  spoke  too  strongly  against  the  dogmatic 
certainty  with  which  the  new  teaching  had  been  proclaimed. 

Regarded  critically,  the  idea  of  intestinal  antisepsis  really  rests 
upon  a  very  weak  foundation ;  for  we  have  httle  knowledge  con- 
cerning the  manner  in  which  putrefactive  products  originate  in  the 
intestines,  as  well  as  the  factors  which  increase  or  diminish  them ; 
and,  furthermore,  we  do  not  know  which  of  these  products  are 
absorbed  and  which  are  not,  nor  how  the  various  foodstuffs  influ- 
ence them.  Through  the  investigations  of  Eovighi^^,  Schmitz  ^^, 
Winternitz  ^^,  and  Albu^^  one  fact  has  been  established — that  milk 
and  its  products  (kefir  and  pot  cheese)  cause  a  diminution  in  the 
ethereal  sulphuric  acids  in  the  urine.  Furthermore,  it  must  be 
remembered  that  inhibition  of  normal  intestinal  motility  results  in 
an  increase  of  putrefactive  products.  If  we  compare  the  conditions 
existing  in  the  stomach  -with  those  in  the  intestines — more  complex, 
it  is  true — we  will  have  a  basis  upon  which  to  study  the  question  of 
intestinal  disinfection.  We  know  to-day  that  the  best  way  in  which 
to  disinfect  the  stomach  is  to  restore  to  it  its  normal  motility. 
Therefore  it  must  be  recognised  that  by  the  mechanical  evacuation 
of  the  stomach,  numerous  fermentative  products  and  their  causes 
are  removed,  and  by  this  means  a  more  favourable  condition  is 
created.  Objectively  this  is  noticeable  in  a  demonstrable  increase 
in  the  strength  of  the  distended  organ.  If  the  normal  motility  be 
lost,  permanent  disinfection  of  the  stomach,  filled  as  it  is  with  micro- 
organisms, is  impossible. 

The  knowledge  gained  from  these  experiences  may  be  applied 
to  the  far  more  complicated  conditions  in  the  intestines  ;  here  also 
the  best  antiseptic  remedy  is  the  restoration  of  normal  peristalsis. 
Therefore  Albu^'''  is  perfectly  correct  if,  in  his  numerous  publica- 
tions upon  this  subject,  he  regards  catharsis  as  the  main  weapon 
with  which  to  combat  intestinal  putrefaction. 


200  DISEASES  OF  THE  INTESTINES 

A  second  scarcely  less  important  means  of  mechanically  com- 
batting the  causes  and  results  of  intestinal  putrefaction  is  careful, 
systematic  intestinal  lavage.  It  is  well  known,  and  we,  too,  have 
repeatedly  pointed  out,  that  decomposition  takes  place  mainly  in  the 
large  intestine ;  the  utility  of  careful  and  repeated  intestinal  lavage 
is  therefore  very  apparent.  By  this  procedure  we  do  not  attempt  to 
sterilize  the  intestine,  nor  do  we  thereby  make  it  impossible  for  new 
microbes  to  develop,  but  we  obtain  at  least  a  relatively  clean  con- 
dition of  the  organ.  Intestinal  lavage  is  beneficial  also  from  an- 
other standpoint :  a  portion  of  the  water  is  absorbed,  causes  an 
increase  in  the  excretion  of  urine,  and  thus,  as  Sahli  was  the  first 
to  show,  numerous  products  of  decomposition  are  washed  out  of  the 
system. 

For  intestinal  lavage  a  number  of  antifermentative  substances 
may  be  added  to  the  water :  salicylic  acid,  boracic  acid,  resorcin, 
creolin,  lysol,  creosote,  ichthyol,  tannic  acid,  and  perhaps  also  for- 
maldehyde and  its  preparations  (amyloform,  dextroform,  paraform, 
tannoform,  etc.).  Yery  little  has  been  published  regarding  the 
last-named  preparations.  Undoubtedly  disinfection  of  the  intestine 
is  best  accomplished  by  means  of  lavage.  As  regards  the  techuic, 
the  only  point  to  be  remembered  is  that  the  irrigation  must  be  con- 
tinued until  the  water  returns  clear.  As  in  gastric  lavage,  so  after 
apparent  cleansing  of  the  intestines,  a  change  in  the  position  of 
the  body  will  often  cause  fresh  fsecal  masses  to  appear  and  be 
washed  away. 

In  spite  of  the  numerous  remedies  which  have  been  recom- 
mended and  tried  within  the  last  decade,  no  important  results  have 
been  obtained  for  the  disinfection  of  the  intestinal  canal  by  way  of 
the  stomach.  Nevertheless,  it  seems  to  me  that  Albn  goes  too  far 
when  he  says  that  internal  antisepsis,  in  the  broadest  sense  of  the 
word,  is  an  unsolvable  problem.  The  solution  certainly  will  not 
be  found  in  a  chemical  agent,  but  rather  in  a  proper  selection  and 
preparation  of  the  ingested  food.  In  the  future,  therefore,  it  should 
be  our  duty  to  study  more  closely  than  heretofore  the  effects  of  the 
various  foodstuffs  npon  decomposition  processes  in  normal  and 
abnormal  conditions.  We  must  cease  to  place  any .  value  upon 
methods  for  the  estimation  of  proteid  decomposition  from  the 
amount  of  ethereal  sulphuric  acid  found,  or  upon  the  relation  be- 
tween preformed  and  total  sulphuric  acid.  Tliis  method  has  led  to 
the  utmost  confusion. 

After  what  has  just  been  said,  it  will  be  unnecessary  to  enumer- 


MEDICINAL  TREATMENT  OP  INTESTINAL  DISEASES        201 

ate  and  discuss  the  numerous  intestinal  antiseptics  wliich  have  been 
recommended.  A  few  of  them,  however  (salol,  orphol,  nosophen, 
bismuth  salicylate,  etc.),  have,  as  already  mentioned,  a  distinct 
value  in  the  treatment  of  chronic  diarrhoea.  This  subject  will  be 
treated  of  in  detail  in  the  chapter  on  Diarrhoea,  in  the  second 
part  of  this  work. 

LITERATURE 

1.  Aubert.     Zeitschr.  f.  rationelle  Medicin,  1852. 

2.  Moreau.     Memoires  de  Physiologie.     Paris,  1877. 

3.  Radziejewski.     Arch.  f.  Anat.  u.  Physiol.,  1870,  S.  37. 

4.  Brieger.     Archiv,  f.  experiment.  Pathol,  u.  Pharmacol.,  Bd.  viii,  S.  335. 

5.  Nothnagel.    Virchow's  Archiv,  Bd.  Ixxxviii,  1884  ;  and  Beitrage  zur  Phys- 

iol, u.  Pathol,  des  Darms,  1884. 

6.  Jacobj.     Archiv  f.  experiment.  Pathol,  u.  Pharmacol.,  Bd.  xxix,  1891. 

7.  Pohl.     Ibid.,  Bd.  xxiv,  Heft  1  u.  2,  1894. 

8.  von  Vämossy.     Deutsche  med.  "Wochenschr.,  1897,  No.  29. 

9.  Ramm.     Ueber  Bittermittel.     Robert's  histor.  Studien  II,  S.  1,  cited  from 

Virchow-Hirsch  Jahresber.,  1890,  Bd.  i,  S.  442. 

10.  Subbotin.     Deutsch.  Arch.  f.  klin.  Med.,  1869,  Bd.  vi,  S.  285. 

11.  Schaefer.     Berliner  klin.  Wochenschr.,  1880,  No.  51. 

12.  Bardet.     Comptes  rendus  de  la  Societe  de  therapeutique,  1895. 

13.  Rovighi.     Zeitschr.  f.  physiolog.  Chemie,  Bd.  xvi. 

14.  Schmitz.     Ibid.,  Bd.  xix,  S.  378. 

15.  Winternitz,     Ibid.,  Bd.  xvi. 

16.  Albu.     Deutsche  med.  Wochenschr.,  1897.  No.  32. 

17.  Ibid.    Loc.  cit.  and  Berliner  klin.  Wochenschr.,  1895,  S.  9. 


PART  II 

SPECIAL    DIVISIOI^ 


CHAPTEK   XIII 

ACUTE  AND    CHEOmC  INTESTINAL    GATARBE 

{Enteritis  acuta  et  chronica) 

1.   Acute  Intestinal  Catarrh 

Preliminary  Remarks. — Acute  intestinal  catarrh  owes  its  im- 
portance not  so  much  to  the  gravity  of  its  symptoms  as  to  the 
frequency  of  its  occurrence.  It  affects  persons  at  all  ages,  more 
particularly,  and  to  a  very  dangerous  degree,  children  during  the 
first  two  years  of  life.  There  is  no  difference  as  regards  sex.  Cer- 
tain periodic  variations,  dependent  upon  atmospheric  and  climatic 
influences,  exist. 

The  causes  of  acute  enteritis,  as  of  acute  catarrhal  gastritis,  are 
very  numerous.  Its  various  forms,  however,  may,  on  the  whole,  be 
traced  to  the  following  four  primary  causes : 

(1)  To  infection  (infectious  catarrhs). 

(2)  To  injurious  substances  in  the  ingested  food  (alimentary  or 

ingestive  catarrhs). 

(3)  To  cold  (refrigeration  catarrhs). 

(4)  To  the  action  of  medicines  or  poisons  (medicinal  or  toxic 

catarrhs). 

Infectious  catarrhs,  according  to  our  present  knowledge,  are  due 
to  bacteria  or  to  their  metabolic  products.  The  sole  primary  mani- 
festation of  the  disease  may  here  be  limited  to  the  intestinal  canal, 
or  the  intestinal  catarrh  may  form  the  chief  or  accompanying  symp- 
tom, or  be  a  complication  of  other  acute  infectious  diseases  (typhoid, 
cholera  nostras  et  asiatica,  pneumonia,  malaria,  anthrax,  influenza, 
sepsis,  etc.). 

We  are  here  concerned  only  with  the  first-named  variety.  A 
priori,  it  seems  probable  that  in  infectious  catarrhs  a  specific  bac- 
terial flora  does  not  exist,  and,  despite  manifold  studies  in  that 
direction,  the  demonstration  of  a  specific  micro-organism  as  the 
cause  of  intestinal  catarrh  has  been  only  partially  successful.  In 
this  connection  we  would  mention  Gaffky's^  demonstration  of  the 

205 


206  DISEASES   OF  THE  INTESTINES 

bacillus  enteritidis  (probably  identical  with  the  bacterium  coli)  in  a 
severe  case  of  infectious  intestinal  catarrh.  An  important  though 
not  necessarily  the  sole  factor  in  the  etiology  of  acute  enteritis  is 
the  bacterium  coli. 

Alimentary  enteritis  is  the  most  common  form  met  with. 
Decomposed  food,  or  else  wholesome  nourishment  ingested  in 
improper  combination  or  in  excessive  quantities  or  of  unsuitable 
physical  character,  may  give  rise  to  violent  intestinal  disturbances, 
which  assume  the  character  of  an  acute  intestinal  catarrh.  Among 
the  foods  which  most  frequently  excite  intestinal  catarrh  are  water, 
ice,  milk  and  its  products  (butter,  cheese,  whey),  meat  and  its  deriv- 
atives, sausages,  fish,  fruit,  etc.  It  has  been  justly  assumed  that 
poisonous  organic  bases  (ptomains)  play  an  essential  part  in  these 
cases.  Some  of  these  have  already  been  determined  (Yaughan's 
tyrotoxicon.  Firth's  lactotoxin,  and  the  ptomains  muscarin,  guani- 
din,  methylguanidin,  dimethylamin,  methylamin,  sethylamin,  beta- 
lin,  mytilotoxin,  etc.,  isolated  by  Brieger).  In  consequence  of 
improper  combination  or  excessive  ingestion  of  otherwise  whole- 
some food,  injurious  products  of  fermentation  (lactic,  butyi'ic,  pro- 
pionic, acetic,  caproic,  formic,  succinic  acids,  etc.)  may  be  formed, 
which,  innocuous  in  ordinary  quantities,  may  under  the  above- 
named  condition  cause  violent  irritation  of  the  intestinal  canal. 

Undoubtedly  we  also  meet  with  diarrhoeas  due  to  exposure  to 
cold,  in  which,  perhaps  owing  to  reflex  vaso-motor  influences,  a 
marked  stimulation  of  the  excito-motor  nerves  is  produced.  When 
the  irritation  is  violent  or  the  patient  careless,  an  acute  intestinal 
catarrh  may  follow. 

Finally,  intestinal  catarrh  may  result  from  the  action  of  drugs, 
either  through  the  use  of  abnormally  large  single  doses  or  from 
the  long-continued  use  of  small  amounts.  Among  these  are  the 
mercurial  preparations  (calomel,  corrosive  subhmate),  arsenic,  anti- 
mony ;  the  emetics — tartar  emetic,  ipecacuanha,  sulphate  of  copper, 
apomorphin;  the  strong  drastic  purgatives  (croton  oil,  colocynth, 
senna,  jalap,  gamboge,  etc.).  Many  other  medicinal  agents,  admin- 
istered in  unsuitable  manner  or  dosage,  may  produce  intestinal 
catarrh;  those  named  above,  however,  are  the  most  frequent 
offenders. 

As  rare  causes  of  acute  enteritis  we  may  mention  traumatism, 
the  presence  of  numerous  entozoa,  and  acute  coprostasis. 


ACUTE  AND   CHRONIC  INTESTINAL  CATARRH  207 

Symptomatology  and  Diagnosis 

The  following  description  relates  solely  to  acute  primary  intes- 
tinal catarrh ;  all  secondary  varieties  of  enteritis — e.  g.,  those  tliat 
occur  in  the  course  of  typhoid  fever,  cholera,  tuberculosis,  malaria, 
pneumonia,  etc.,  carcinoma  of  the  intestines,  congestion  of  the  por- 
tal circulation,  intestinal  ulcerations,  intestinal  strictures,  entozoa, 
etc. — will  not  here  be  considered,  because  foreign  to  the  present 
discussion.  As  regards  the  intensity  and  extension  of  the  process, 
the  symptomatology  of  acute  enteritis  presents  a  variety  of  gradu- 
ated stages,  so  that  it  is  difficult  to  faithfully  describe  all  grades  and 
forms  of  the  disease.  The  following  description  applies  to  a  moder- 
ately severe  case  of  enterocolitis.     Of  especial  importance  are  : 

1.  The  commencement  of  the  process. 

2.  The  gastro -intestinal  disturbances. 

3.  The  patient's  general  condition. 

4.  The  course  of  the  disease.  , 
Certain  other  symptoms,  which  will  be  discussed  below,  may 

complete  the  clinical  picture. 

As  a  rule,  the  symptoms  appear  suddenly  and  without  prodrom- 
ata,  almost  immediately  following  the  exciting  cause.  Tormenting, 
dragging,  and  boring  pains  are  felt  in  the  abdomen,  usually  accom- 
panied by  general  discomfort,  nausea,  and  occasionally  even  by 
attempts  at  vomiting.  Diarrhoea  soon  develops.  The  number  and 
character  of  the  evacuations  vary  according  to  the  localization, 
intensity,  and  etiology  of  the  disease.  Thus  in  very  mild  cases 
there  may  be  two  to  three,  in  severe  cases  iifteen  to  twenty  or 
more  passages.  The  first  evacuations  may  still  be  solid  or  pasty, 
but  the  more  numerous  they  become  the  more  fluid  and  odour- 
less will  they  be.  Should  the  catarrh  involve  the  upper  portions  of 
the  small  intestine,  we  may  recognize  its  site  from  the  greenish- 
yellow  colour  of  the  dejecta  and  from  the  presence  of  unchanged 
bile  pigments  (Gmehn's  reaction).  If  the  catarrh  is  limited  to  the 
large  intestine  this  test  can  no  longer  be  employed,  since  the  bili- 
rubin has  already  been  converted  into  urobilin. 

All  the  stools-  of  acute  enteritis  contain  an  admixture  of  muctis, 
partly  in  the  form  of  exceedingly  small,  barely  visible  gelatinous 
particles  or  minute  specks  intimately  mixed  with  the  stool,  partly 
in  the  form  of  isolated  masses  which  consist  of  small  or  large  shreds. 
Besides  mucus,  blood  is  not  infrequently  present,  partly  as  small 
streaks  usually  adherent  to  the  particles  of  mucus,  partly  in  the  form 


208  DISEASES   OP   THE  INTESTINES 

of  larger  bright  red  or  coagulated  masses,  also  generally  mixed  with 
the  latter.  In  my  experience  copious  hemorrhage  is  very  rare 
in  acute  enteritis.  In  the  majority  of  cases  of  uncomplicated 
enteritis,  unlike  those  of  dysentery,  ])us  is  not  present  in  the  evac- 
uations. Owing  to  the  active  gas  formation  within  the  intestines, 
the  faeces  may  present  a  marked  frothy  appearance.  Besides  mucus, 
the  microscopical  picture  reveals  red  and  white  blood-corpuscles, 
and  frequently  partly  fresh  but  mostly  disintegrated  epithelium. 
We  also  find  various  kinds  of  food  remnants,  particles  of  casein, 
muscle  fibres,  starch  granules,  renmants  of  cellulose,  and  other  acci- 
dental constituents  of  food. 

Gastric  digestion  is  frequently  interfered  with  along  with  the 
intestinal  disturbance.  The  appetite  is  generally  absent,  direct 
aversion  to  food  is  occasionally  present ;  in  other  cases,  gastric  dis- 
turbances— nausea,  vomiting,  epigastric  pressure — are  so  prominent 
that  the  case  resembles  one  of  acute  gastritis.  The  tongue  is 
usually  coated  ;  a  disgusting  fetor  is  present ;  thirst  is  frequently 
tormenting.  There  is  an  inverse  relation  between  the  number  of 
stools  and  the  thirst  on  the  one  hand,  and  the  urinary  secretion  on 
the  other. 

The  general  condition  depends  essentially  on  the  severity  of  the 
enteritis  and  the  number  of  evacuations.  Only  in  very  few  cases 
does  it  remain  undisturbed ;  in  the  greater  number  of  cases  the 
patient  complains  of  considerable  lassitude,  which  in  children,  in 
the  aged,  or  in  otherwise  weakened  individuals  not  infrequently 
develops  into  sym.ptoms  of  grave  prostration.  Under  these  circum- 
stances, a  condition  of  acute  hydrocephalus,  as  described  by  Marshall 
Hall,  may  supervene,  due  to  the  copious  intestinal  discharges  and 
the  resulting  cerebral  anaemia. 

In  the  vast  majority  of  cases,  especially  in  adults,  the  disease 
runs  a  favourable  course  and  is  of  relatively  short  duration.  N^ever- 
theless,  we  occasionally  observe,  especially  in  colitis,  quite  severe 
and  protracted  forms,  in  which  convalescence  is  long  delayed. 
Other  cases  are  characterized  by  a  persistent  vulnerability  of  the 
intestine,  so  that  under  predisposing  conditions  relapses  frequently 
occur ;  the  process  does  not  go  on  to  perfect  recovery,,  a  chronic 
enteritis  gradually  develops,  or  a  more  or  less  intractable  atony  of 
the  large  intestine,  accompanied  by  constipation,  remains. 

Certain  complicating  conditions  may  be  added  to  this  typical 
picture.  The  disease,  which  usually  runs  an  afebrile  course,  may 
be  accompanied  by  more  or  less  severe  fever,  so  as  to  awaken  the 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  209 

suspicion  of  a  beginning  typhoid,  tlie  more  so  as  enlargement  of 
the  spleen  is  occasionally  observed.  The  urine  is  generally  con- 
centrated and  dark;  in  rare  instances  anuria  may  develop.  It 
has  been  observed  by  various  authors,  first  by  Kjellberg  ^  and  soon 
after  by  Hermann^  and  Mühlhauser ■*,  that  albuminuria  may  oc- 
cur in  cholera  diarrhoeas ;  and  Kobler  ^  has  recently  reported  two 
cases  of  cholera  nostras,  in  which  for  a  long  time  there  was  a 
marked  diminution  of  urine  with  albumin  and  large  quantities 
of  hyaline  and  epithelial  casts.  In  one  case  granular  casts  and 
renal  epithelium  could  also  be  demonstrated.  Even  in  the  milder 
forms  of  diarrhoea,  as  first  shown  by  Fischl  ^  and  corroborated  by 
Stiller'',  temporary  albuminuria  and  cylindruria  may  occur.  I  re- 
cently made  the  same  observation  in  an  elderly  patient,  in  whom 
on  the  second  day  of  an  acute  gastro-enteritis  I  found  an  appre- 
ciable amount  of  albumin  in  his  urine  (without  casts).  With  the 
improvement  of  the  intestinal  catarrh  the  albuminuria  soon  dis- 
appeared. 

In  exceptional  cases  in  children,  according  to  Turner^,  fatal 
Bright's  disease  may  follow  an  acute  gastro-enteritis. 

Several  authors  (Strümpell^,  Fleischer ^*^)  report  the  occurrence 
of  acute  pains  in  the  joints  and  muscles,  as  well  as  tumefaction  of 
the  joints,  as  a  complication  of  acute  enteritis.  Herpes  labialis  has 
also  been  observed  in  infectious  intestinal  catarrh. 

As  a  rule,  the  diagnosis  of  an  acute  enteritis  is  not  difficult,  espe- 
cially where  a  positive  etiological  factor  (errors  in  diet,  cold,  etc.) 
points  to  the  origin  of  the  disease.  The  diagnosis  is  based  on  the 
acute  onset,  the  characteristic  gastro-intestinal  disturbances,  and  the 
course  of  the  disease.  Compared  with  these  data,  the  objective 
abdominal  symptoms  are  of  subordinate  importance.  Inspection 
may  reveal  a  slight  distention,  although  this  may  be  absent;  in 
greatly  emaciated  persons,  isolated  spasmodic  intestinal  contractions, 
especially  of  the  small  bowel,  are  occasionally  observed.  If  the  colon 
is  especially  affected,  palpation  elicits  some  tenderness  on  pressure, 
particularly  pronounced  in  the  region  of  the  descending  colon  and 
the  sigmoid  flexure,  and  thus  may  indicate  the  Hmits  of  the  inflam- 
mation. In  diffuse  enteritis,  the  whole  abdomen,  especially  the  cir- 
cumbilical  portion,  is  the  seat  of  more  or  less  decided  tenderness. 
1^0  practical  data  are  obtained  by  percussion.  Auscultation  enables 
us  to  hear  loud  borborygmi  and  other  intestinal  sounds  even  at  a 
distance,  and  better  still  when  the  ear  is  directly  applied  to  the 
abdominal  wall.     If  we  except  the  gastro-duodenal  catarrh  accom- 


210  DISEASES  OP  THE   INTESTINES 

panied  by  jaundice  which,  will  be  considered  later,  the  localization 
is  more  difficult  than  the  diagnosis  of  the  diseased  process.  In  my 
opinion,  the  only  determination  of  some  practical  value  is  whether 
the  seat  of  the  catarrh  is  in  the  large  or  small  intestines.  The 
absence  of  large  appreciable  masses  of  mucus  and  blood  from  the 
stools  and  the  presence  of  unconverted  bile  pigment  is  diagnostic 
of  catarrh  of  the  small  intestine,  while,  conversely,  the  presence  of 
a  larger  quantity  of  mucus  and  blood  in  the  feeces  argues  in  favour 
of  disease  of  the  colon.  K  we  go  still  further,  and  attempt  to  localize 
the  catarrh  in  the  different  intestinal  segments,  we  are  no  longer 
treading  upon  scientific  ground. 

In  view  of  the  symptoms  above  mentioned  we  will  meet  with 
diagnostic  difficulties  only  in  exceptionally  complicated  cases.  Thus, 
for  example,  during  the  first  days  of  febrile  gastro-enteritis*  the 
differentiation  from  typhoid,  as  already  stated,  may  be  exceedingly 
difficult,  and  may  only  become  possible  after  careful  observation 
of  the  course,  of  the  disease.  This  same  difficulty  confronts  us  in 
cholera  asiatica,  particularly  when  that  disease  is  epidemic.  In  both 
instances  the  bacteriological  and  the  serum  examination  (WidaPs 
reaction)  may  materially  assist  the  formation  of  a  diagnosis. 

The  diagnosis  of  duodenal  catarrh  conforms  completely  with 
that  of  acute  and  subacute  gastric  catarrh,  and  only  becomes  possi- 
ble with  the  onset  of  catarrhal  jaundice.  Its  symptom-complex 
is  generally  so  pronounced  that  a  special  description  seems  super- 
fluous. 

In  my  opinion,  the  differential  diagnosis  between  acute  colitis 
and  the  milder  forms  of  dysentery  is  exceedingly  difficult ;  I  be- 
lieve that  we  are  as  yet  unable  to  satisfactorily  discriminate  between 
these  two  diseases.*  In  pronounced  cases,  and  particularly  during 
epidemics,  the  diagnosis  is  probably  less  difficult.  In  tro]3ical  dys- 
entery, the  presence  of  the  amoeba  coli  (Loesch)  in  the  f^ces  and  in 
the  pus  of  the  liver  abscesses  is  of  diagnostic  importance. 

The  treatment  of  acute  intestinal  catarrh  is  based  upon  the  fol- 
lowing principles : 

1.  The  removal  of  noxious  material  from  the  intestinal  canal 

(indicatio  causalis). 

2.  The  greatest  possible  protection  of  the  gastro-intestinal  canal 

(indicatio  symptomatica). 

*  That  this  same  difficulty  has  been  encountered  by  other  authors  is  obvious 
from  the  fact  that  in  literature  we  not  infrequently  meet  with  the  designation 
"  dysenteroid  intestinal  catarrh." 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  211 

We  are  not  always  able  to  carry  out  the  first  rule,  since  only  in 
a  certain  proportion  of  cases  are  the  noxious  materials  of  a  sub- 
stantial nature.  Where  this  indication  can  be  fulfilled,  recovery,  as 
a  rule,  immediately  follows  the  removal  of  the  undigested  masses. 
Frequently  this  result  is  also  brought  about  by  the  products  of 
decomposition  themselves,  which  accumulate  in  the  intestinal  canal 
and  excite  increased  peristalsis.  Further  treatment  is  then  hardly 
necessary.  Where,  however,  in  spite  of  the  obvious  presence  of 
noxious  material,  the  evacuations  are  arrested  or  insufficient,  the 
removal  of  this  material  by  a  suitable  purge  is  of  primary  impor- 
tance. For  this  purpose,  calomel  (0,2  to  0.3  grams,  every  three 
hours)  [until  the  desired  effect  is  obtained]  or  castor  oil  (in  doses  of 
one  to  two  tablespoonf uls)  is  preferable. 

Since  the  early  days  of  medicine  it  has  been  customary  to  give 
calomel  preferably  in  "infectious"  catarrhs,  and  castor  oil  in  cases 
due  simply  to  errors  in  diet ;  still,  the  superiority  of  the  one  over 
the  other  is  by  no  means  established.  In  my  opinion,  both  act  as 
disinfectants  by  rapidly  and  thoroughly  emptying  the  bowels. 

The  second  indication — protection  of  the  gastro-intestinal  canal 
— must  be  considered  after  the  first  has  been  fulfilled,  or  where, 
owing  to  the  absence  of  recognisable  etiological  factors,  this  is  unat- 
tainable. This  second  indication  is  principally  fulfilled  by  complete 
rest  in  bed  for  several  days,  by  constant  and  uniform  application  to 
the  abdomen  of  heat  in  the  shape  of  warm  fomentations,  and  most 
especially  by  a  proper  diet.  For  the  first  two  or  three  days  the 
diet  should  consist  of  fluids  only.  All  liquids,  however,  are  not 
suitable  ;  for  example,  milk  is  contra-indicated  in  all  forms  of  acute 
enteritis.  Cold  drinks  as  well  as  carbonated  waters  should  also  be 
avoided,  excepting  when  severe  vomiting  is  also  present  for  ex- 
perience has  shown  that  ice  and  iced  drinks  tend  to  check  the 
nausea.  In  acute  cases  the  diet  should  therefore  be  limited  to  the 
following :  watery  gruels,  thin  bouillon  without  salt  or  spices,  tea 
or  cocoa  made  with  water  alone  (no  sugar,  but  in  its  stead  saccha- 
rin), claret  with  or  without  water,  q^^  albumen,  decoctions  of  arrow- 
root and  hygiama  gruels,  etc.  Carminative  teas  are  also  frequently 
useful — e.  g.,  peppermint,  valerian,  fennel,  anise  seed,  thyme,  cara- 
way, marsh  mallow,  etc. 

Only  after  the  intestine  has  become  absohctely  quiescent,  and 
tenderness  to  pressure  has  disappeared,  may  we  increase  the  diet  by 
adding  one  or  more  softened  zwiebacks,  next  permitting  the  lightest 
forms  of  meat  and  fish,  with  some  boiled  rice  or  mashed  potatoes, 


212  DISEASES  OF  THE  INTESTINES 

gradually  approaching  the  ordinary  diet.  The  patient  should  be 
instructed  to  carefully  abstain  from  excesses  in  food  and  drink  for 
a  number  of  weeks,  to  avoid  all  indigestible,  fatty,  tough  foods, 
and  also  those  rich  in  cellulose,  for,  as  previously  stated,  the  intes- 
tine is  very  vulnerable  for  a  long  time. 

These  measures  are  all  that  are  required  for  the  cure  of  a  large 
number  of  cases.  It  will  only  exceptionally  be  found  necessary  to 
control  excessive  diarrhoea,  or,  on  the  other  hand,  to  combat  a  reac- 
tive constipation  or  to  stimulate  a  failing  appetite.  The  first  is 
accomplished  by  the  administration  of  opiates  in  the  form  of  tinc- 
ture of  opium  (10  to  15  drops,  repeated  one  to  four  times)  or 
the  extract  of  opium  (0.03,  repeated  two  or  three  times  a  day),  in- 
ternally or  in  suppositories.  I  regard  the  continued  administration 
of  opiates  not  only  as  unnecessary  but  even  as  injurious.  When, 
as  frequently  happens,  constipation  occurs  after  the  diarrhoea 
has  subsided,  this  must  not  he  treated  by  purgatives,  but  only 
by  suitable  enemata  of  oil  or  of  soapsuds.  The  appetite  gen- 
erally returns  in  due  course  of  time.  It  may  be  stimulated  by 
the  well-known  stomachics  (the  fluid  extract  or  decoction  of  con- 
durango,  the  tincture  of  nux  vomica,  the  compound  tincture  of 
cinchona,  etc.). 

In  conditions  of  grave  collapse  we  may  endeavour  to  arouse  the 
heart's  action  by  stimulants  administered  internally  (e.  g.,  wine, 
cognac,  ether)  or  subcutaneously  (e.  g.,  oil  of  camphor,  citrate  of 
caff  ein). 

2.    Chronic  Intestinal  Catarrh 

Preliminary  Remarlcs. — Chronic  enteritis  may  result  from 
acute  intestinal  catarrhs  in  which  recovery  has  taken  place  only 
incompletely  or  not  at  all,  or  from  long-continued  and  various 
kinds  of  injuries  of  the  intestinal  canal.  Among  the  injurious 
agents  which  conduce  to  chronic  intestinal  catarrh,  those  which 
directly  affect  the  gastrointestinal  mucous  membrane  are  the  most 
important  and  the  most  frequent.  These  include  improper  food, 
frequent  colds,  abuse  of  purgatives,  constipation,  etc.  The  pjri- 
mary  forms  of  enteritis  are  caused  in  this  manner.  As  distin- 
guished from  these,  the  secondary  forms  are  those  which  develop 
either  in  connection  with  gastric  diseases  (e.  g.,  catarrhs,  carcinoma, 
fermentation,  etc.)  or  from  intestinal  diseases  (tumours,  ulcerations, 
stenoses,  adhesions,  displacements,  etc.).  The  intestinal  catarrh  is 
often   overshadowed    by  the  other  predominant   symptoms,   or  it 


ACUTE  AND   CHRONIC  INTESTINAL  CATARRH  213 

may  be  so  prominent  that  the  etiological  factor  is  only  of  second- 
ary clinical  importance.  Nothnagel  ^^  correctly  remarks  that  a  con- 
gestive enteritis,  in  the  true  sense  of  the  word,  does  not  exist ;  at 
the  most,  we  may  concede  that  hyperaemia  of  the  intestinal  tract 
creates  conditions  favourable  to  the  development  of  chronic  catarrhs. 
As  a  matter  of  fact,  I  believe  they  occur  very  rarely  as  secondary 
catarrhs  dependent  upon  the  main  disease ;  and  when  they  do  occur, 
who  can  prove  that  they  have  developed  in  this  way,  and  are  not 
accidental  complications  ? 

Clinical  observation  combined  with  post-mortem  examination 
teaches  us  that  we  must  distinguish  between  different  grades  and 
forms  of  enteritis,  and  that  these  affect  various  intestinal  segments. 
For  the  better  understanding  of  this  I  preface  my  remarks  with  a 
short  description  of  the  pathologico-anatomical  changes  that  are 
found. 

On  macroscopical  examination  of  such  a  diseased  bowel  the  attention  is 
immediately  arrested  by  a  brown  or  black  pigmentation  of  the  mucous  mem- 
brane, which  particularly  affects  the  region  of  the  villi  and  that  of  the  fol- 
licles. Peyer's  patches  may  also  present  such  discolourations,  caused  by  old 
hemorrhages.  The  histological  changes  involve  chiefly  the  mucosa ;  they  may 
also  involve  the  submucosa,  or  the  muscularis.  The  changes  may  consist  of 
a  cellular  infiltration  of  the  interstitial  connective  tissue  (leucocyte  infiltra- 
tion), from  which  a  genuine  hypertrophy  of  the  connective  tissue  may  develop 
and  this  may  occur  to  such  a  degree  that  the  intestinal  lumen  becomes  nar- 
rowed for  quite  some  distance.  In  other  cases  there  is  a  polypoid  prolifera- 
tion of  the  tissues.  In  still  other  instances  there  are  cystic  dilatations  (enteritis 
chronica  cystica),  produced  by  strangulation  of  conglomerations  of  glands. 
Usually  the  cysts  are  small  and  hardly  visible  to  the  naked  eye,  but  they  may 
attain  the  size  of  a  pin's  head  or  a  lentil.  Their  contents  consist  of  a  peculiar 
slimy,  viscid  fluid,  whose  clinical  nature  has  not  as  yet  been  positively  de- 
termined. In  contrast  to  these  plastic  inflammatory  processes  a  degenerative 
form  can  also  be  distinguished.  This  affects  the  glands  rather  than  the  con- 
nective tissue,  destruction  and  atrophy  of  the  glands  gradually  occurring  as  a 
result  of  the  marked  epithelial  desquamation.  At  the  same  time  the  other 
layers  of  the  mucous  membrane  generally  lose  their  powers  of  resistance.  The 
mucosa  becomes  thin  and  lamellated,  the  villi  atrophied,  so  that  on  section  we 
are  only  able  to  recognise  isolated  remnants  projecting  from  the  general  level 
of  the  mucous  membrane.  Besides  these  changes,  the  process  especially  affects 
the  intestinal  follicles,  which  are  swollen  at  first  and  are  surrounded  by  a  hyper- 
semic  zone ;  later  they  I'upture,  and  thus  give  rise  to  so-called  follicular  (len- 
ticular) ulcers.  In  addition  to  these  last,  other  erosions  result  from  desquama- 
tion and  loss  of  epithelium.  At  first  they  are  superficial,  but  through  their 
confluence  and  deeper  extension  true  catarrhal  ulcerations  may  gradually  be 
formed. 

15 


214  DISEASES  OF  THE  INTESTINES 

Pathological  anatomy  not  only  distinguishes  between  the  variety, 
but  also  between  the  situations  of  morbid  processes,  and  hence 
speaks  of  a  duodenitis,  jejunitis,  ileitis,  colitis,  and  j)rocUiis. 
Clinically,  these  fine  distinctions  can  not  be  made,  and  we  must  be 
content  with  a  division  into  catarrh  of  the  small  and  catarrh  of 
the  large  intestines. 

Since  catarrhs  of  the  small  and  of  the  large  intestines,  however, 
frequently  coexist,  we  must  also  consider  this  combination  clinically. 
In  an  anatomical  sense  the  one  will  naturally  preponderate  over 
the  other,  while  the  one  intestinal  division  is  extensively  diseased, 
only  a  small  portion  of  the  other  will  be  affected.  In  the  present 
state  of  our  knowledge  these  fine  gradations  can  scarcely  be  made, 
and  in  view  of  the  great  number  of  variations  met  with  they  are  of 
little  practical  value.  The  clinical  diagnosis,  therefore,  will  have 
to  deal  mainly  with  the  following  two  questions  : 

1.  Is  an  intestinal  catarrh  really  present  ? 

2.  Does  it  involve  the  small  or  large  intestine  alone,  or 
both  ? 

In  the  following  we  will  first  outline  the  general  symptoms  of 
intestinal  catarrh,  and  then  will  consider  its  localization. 

General  Symptomatology  and  Diagnosis  of  Chkonic 
Intestinal  Catarrh 

In  chronic  intestinal  catarrh  the  clinical  picture  is  mainly  formed 
by  the  subjective  symptoms,  or  by  objective  abdominal  manifesta- 
tions— especially,  marked  variations  in  the  number  and  character 
of  the  stools. 

The  subjective  symptoms  vary  greatly  in  degree.  They  may 
be  absent,  or  may  only  manifest  themselves  by  disturbances  of  def- 
ecation ;  they  may  be  only  just  felt,  or  may  constitute  the  main 
complaint  of  the  patient ;  they  are  constant  or  periodical,  may 
disappear  with  or  without  the  objective  symptoms,  or  vice  versa ; 
they  may  persist,  notwithstanding  the  cessation  of  the  characteristic 
intestinal  symptoms.  Daily  observation  furnishes  numerous  ex- 
amples of  all  the  variations.  "We  will  have  to  refrain  from  de- 
scribing them  all,  since  an  exhaustive  description  would  not  be  pos- 
sible. We  shall,  however,  describe  a  few  forms  of  chronic  enteritis 
that  are  of  practical  importance. 

In  typical  cases  of  chronic  intestinal  catarrh  the  symptoms  con- 
sist in  feelings  of  discomfort  or  pressure,  pain  or  soreness  in  the 
abdomen,  combined  with  intestinal  rumbling  and  hyperperistalsis, 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  215 

followed  usually  by  copious  alvine  evacuations.  In  marked  cases 
these  symptoms  may  be  constant,  or  they  may  occur  only  in  parox- 
ysms— e.  g.,  following  a  slight  cold,  excessive  mental  or  bodily  exer- 
tion, dietetic  errors,  mental  excitement,  etc.  The  patient  at  the  same 
time  has  a  sense  of  intense  discomfort,  of  bodily  and  mental  depres- 
sion, to  which  are  sometimes  added  salivation,  retching,  or  actual 
vomiting.  Where  the  intestinal  catarrh  is  situated  very  far  down, 
painful  tenesmus  is  also  present.  In  atypiGal  or  less  marked 
cases  the  symptoms  are  confined  to  uncomfortable  painful  sen- 
sations which  involve  the  whole  abdomen,  or  else  are  limited 
to  certain  areas — e,  g.,  the  umbilical  region  or  portions  of  the 
large  intestine.  When  gas  or  fseces  are  passed  these  sensations 
may  rapidly  disappear.  I  would  call  particular  attention  to  the 
frequent  occurrence  of  this  form  of  intestinal  catarrh,  for  I  am 
convinced  it  is  only  rarely  recognised,  since  it  may  be  accompa- 
nied by  apparently  normal  faecal  evacuations.  By  careful  observa- 
tion and  questioning  of  the  patient,  but  especially  from  an  exami- 
nation of  the  dejecta,  we  may  convince  ourselves  that  these  patients 
are  affected  with  a  slight  or  only  partially  healed  intestinal  catarrh. 
This  will  be  again  referred  to  in  discussing  the  diagnosis.  In 
another  form  of  intestinal  catarrh — the  coprostatic — the  subjective 
symptoms  are  entirely  different.  The  above-mentioned  symptoms 
are  either  entirely  absent,  or  they  appear  as  periodic  intestinal  colics, 
with  spastic  obstipation,  or  else  in  the  form  of  a  constant  or  very 
frequent  feeling  of  pressure  in  the  dependent  portions  of  the  intes- 
tines, or  even  as  meteorism  accompanied  by  more  or  less  marked 
flatulency. 

Between  these  two  extremes  we  meet  with  cases  in  which  the 
lirst-described  combine  in  the  most  diverse  manner  with  the  last- 
described  varieties. 

The  general  condition  of  patients  suffering  from  chronic  enteri- 
tis varies  very  markedly.  As  a  rule,  it  is  only  slightly  altered  from 
the  normal  in  constipating  enteritis,  but  very  much  more  so  in  that 
form  accompanied  by  copious  diarrhoea,  especially  where  the  upper 
portions  of  the  intestine  are  principally  affected.  Occasionally, 
however,  we  meet  with  chronic  diarrhoeas  in  which  there  is  no 
deterioration  of  the  general  health,  while,  on  the  other  hand,  it  is 
not  rare  to  find  cases  of  constipating  enteritis  in  which  the  bodily 
weight  and  general  condition  have  been  gravely  affected.  This 
variable  behaviour  can  not  in  all  cases  be  explained  alike.  In  a 
great  number  the  psychic  factor — i.  e.,  the  general  depression — no 


216  DISEASES  OF  THE  INTESTINES 

doubt  exerts  an  unfavourable  influence  upon  the  ingestion  of  food  ; 
in  others,  again,  the  loss  of  fluids  is  the  main  cause ;  in  still  others 
an  irregular  mode  of  life,  errors  of  diet,  excessive  bodily  or  mental 
work,  will  cause  a  loss  of  streng-th  and  weight.  The  longer  the  dis- 
ease exists  and  the  more  frequently  curative  measures  fail  to  bring 
relief,  the  sooner  will  the  patient  present  a  certain  neurasthenic 
tendency,  which  may  even  to  the  most  experienced  physician 
obscure  the  true  cause  of  the  malady. 

The  objective  examination  is  divided  into  that  of  the  abdomen 
and  that  of  the  dejecta.  In  the  flrst,  jpalpation  alone  possesses  posi- 
tive value.  Percussion  and  auscultation  may  perhaps  demonstrate 
the  existence  of  meteorism,  of  accumulated  faeces,  of  abnormally 
increased  intestinal  sounds,  but  they  do  not  of  themselves  permit 
of  any  conclusions  as  to  the  existence,  location,  or  extent  of  the 
intestinal  catarrh.  On  the  other  hand,  palpation  may  sometimes 
be  of  value  in  determining  a  tenderness  of  certain  intestinal  areas, 
thus,  as  will  be  later  explained,  indicating  the  seat  of  the  intestinal 
catarrh.  The  evacuations  vary  very  much,  according  to  the  natm-e 
and  seat  of  the  disease.  The  movements  may  be  tardy,  or  may 
occur  at  regular  intervals ;  they  may  occur  too  frequently  or  in 
excessive  amount,  or  after  several  days  of  constipation  there  may 
suddenly  be  a  single  or  repeated  diarrhoeal  movement ;  or,  finaEy, 
after,  a  period  of  days  or  weeks  of  perfect  health,  suddenly,  and 
often  without  any  recognisable  cause,  ä  normal  stool  may  assume  a 
diarrhoeal  character. 

Of  stiU  greater  importance  are  the  changes  in  the  composition 
of  the  faeces,  as  well  as  the  presence  of  abnormal  admixtures,  par- 
ticularly the  constant  occurrence  of  mucus.  The  change  in  com- 
position may  be  due  to  an  increased  amount  of  undigested  foodstuffs, 
which  can  sometimes  be  recognised  macroscopically,  but  better  still 
microscopically. 

The  presence  of  mucus  is  the  most  frequent  and  most  charac- 
teristic symptom  of  intestinal  catarrh.  The  amount  of  mucus 
voided  varies  greatly,  however,  according  to  the  seat  of  the  disease ; 
this  will  again  be  referred  to  in  the  discussion  on  the  localization 
of  intestinal  catarrh.  The  presence  of  mucus  in  one  movement 
does  not  conclusively  prove  the  existence  of  an  intestinal  catarrh, 
neither  does  its  absence  exclude  the  same.  The  first  statement  will 
scarcely  be  denied ;  it  is  important,  however,  to  emphasize  the  fact 
that  severe  catarrhal  conditions  may  exist  without  the  production 
of  mucus.     Thus,  since  Nothnagel's^^  investigation  on  this  subject. 


ACUTE   AND  CHRONIC  INTESTINAL   CATAREH  21Y 

it  has  generally  been  accepted,  and  I  believe  with  perfect  justice, 
that  in  atrophy  of  the  intestine  (which,  by  the  way,  frequently 
eludes  a  positive  diagnosis)  mucus  is  entirely  absent  from  the 
dejecta.  An  admixture  of  blood  is  not  one  of  the  characteristics 
of  primary  enteritis ;  it,  as  well  as  pus,  represents  only  one  of  the 
complications. 

The  course  of  chronic  enteritis  is  tedious  and  protracted. 
Undoubtedly  a  functional  cure  is  sometimes  achieved.  If  we  con- 
sider analogous  conditions  of  other  organs  (the  stomach,  the  urethra, 
the  larynx,  the  uterus),  it  is  at  least  doubtful  whether  there  are  ever 
any  cures  in  an  anatomical  sense.  The  following  experience,  which 
undoubtedly  other  physicians  have  also  had,  is  very  interesting, 
viz. :  after  a  catarrh  lasting  for  many  years,  a  sudden  change  in  its 
character  may  occur — i.  e.,  chronic  diarrhoea  may  gradually  give 
place  to  a  marked  tendency  toward  constipation,  or  vice  versa.  In 
these  cases  there  have  been  changes  in  the  mechanism  of  innerva- 
tion, the  nature  of  which  is  as  yet  entirely  unknown  to  us. 

If  we  consider  the  picture  outlined  in  the  foregoing  pages,  the 
diagnosis  of  chronic  enteritis  in  marked  cases  is  not  especially  dif- 
ficult. It  is  more  difficult,  however,  in  atypical  cases,  and  particu- 
larly its  differentiation  from  simple  functional  diarrhoeas  is  an 
extremely  delicate  problem.  There  is  no  objective  symptom  in 
the  latter  that  may  not  also  be  present  in  catarrh.  From  numer- 
ous personal  observations,  I  can  state  that  mucus,  undigested  food 
remnants,  and  bile  pigment  may  be  present  in  nervous  diarrhoea  as 
in  intestinal  catarrh.  An  analysis  of  such  cases  shows — and  this 
is  perhaps  the  key  to  the  proper  understanding  of  these  compli- 
cated conditions — that,  in  consequence  of  a  continued  chemical  and 
mechanical  irritation  of  the  intestinal  mucous  membrane,  a  true 
intestinal  catarrh  may  be  developed  from  a  purely  functional  diar- 
rhoea. For  the  elucidation  of  these  diflacult  questions,  an  exact 
previous  history  and  status  praesens,  particularly  as  to  the  nervous 
system,  are  very  necessary.  We  thus  learn  that  the  disease  occurs 
paroxysmally,  that  it  is  frequently  increased  by  psychic  excitement 
or  mental  and  bodily  fatigue,  that  during  rest  it  subsides  or  inter- 
mits, and  that  also  in  the  latter  case  an  occasional  dietetic  error  is 
borne  without  injurious  results,  etc.  Objectively,  other  signs  of 
hysteria  or  neurasthenia  may  be  present :  increased  reflexes,  local 
hyp-  or  hyperalgesia,  autographia,  vasomotor  disturbances,  etc. 

In  spite  of  all  these  diagnostic  auxiliaries,  we  entirely  agree 
with  ^Nothnagel  that  the  diagnosis  can  frequently  be  made  only 


218  DISEASES  OF  THE  INTESTINES 

ex  juvcmtihus  et  nocentihus.  In  discussing  nervous  diarrlioea,  we 
shall  again  refer  to  the  individual  symptoms. 

As  indicated  above,  the  abortive  or  ill-defined  cases  of  intestinal 
catarrh  are  also  of  practical  interest.  These  may  occur  with  appar- 
ently normal  intestinal  evacuations,  and  manifest  themselves  by 
occasional  painful  abdominal  sensations.  A  careful  examination  of 
the  faeces  will,  however,  reveal  the  characteristic  signs  of  intestinal 
catarrh,  now  to  be  described. 

For  the  diagnosis  of  intestinal  catarrh,  aside  from  the  less  posi- 
tive data  obtained  from  physical  examination  of  the  abdomen,  there 
are  in  reality  only  two  other  methods  of  examination :  test  lavage  of 
the  intestine  (see  page  8Y)  and  the  examination  of  the  dejecta. 
The  first  method  at  once  shows  whether  the  large  intestine  is  the 
seat  of  a  chronic  irritation  attended  with  hypersecretion  of  mucus, 
and  should  for  this  reason  never  be  omitted  in  any  [suspected]  case 
of  intestinal  catarrh.  Under  certain  circumstances  examination  of 
the  dejecta  may  decide  the  diagnosis ;  it  may  show  the  presence  of 
abnormal  undigested  matter  or  of  certain  admixtures  (especially 
mucus)  as  prominent  constituents  of  the  f^ces.  Regarding  the 
undigested  foodstuffs,  we  must  at  present  be  satisfied  with  the 
gross  differentiation  derived  from  the  comparison  of  the  normal 
with  the  abnormal  stool.  A  positive  functional  test  of  the  intes- 
tine alone  will  furnish  us  with  an  exact  knowledge  of  the  devia- 
tions from  the  normal. 

For  the  examination  of  mucus  and  other  abnormal  constituents, 
see  above,  page  96  et  seq. 

Diagnosis  of  Catarrh  of  the  Small  Intestine 

The  main  symptom  of  catarrh  of  the  small  intestine  is  the 
anomalous  condition  of  the  faeces.  The  subjective  symptoms  pre- 
viously mentioned  are  also  of  some  value. 

With  the  exception  of  the  dejecta  (soon  to  be  described),  the 
most  important,  at  times  the  most  diagnostic  objective  symptom,  is 
the  presence  of  a  well-defined  pressure  sensitiveness.  In  my 
experience,  catarrh  of  the  small  intestine  may  sometimes,  at  first 
sight,  be  differentiated  from  that  of  the  large  intestine  by  this 
means.  While  objective  tenderness  is  either  entirely  absent  in  the 
former,  or,  when  present,  is  usually  elicited  only  in  the  mesogas- 
trium  above  or  below  the  umbilicus  (especially  in  tuberculous  diar- 
rhoea), diffuse  tenderness  on  pressure  is  frequently  found  in  chronic 
catarrh  of  the  large  bowel;  although  rare  in  the  region  of  the 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  219 

caecum,  it  is  well-pronounced  over  the  sigmoid  flexure  and  descend- 
ing colon. 

In  these  cases  the  evacuations  are  usually  diarrhoeal.  But,  as 
Ils^othnagel  has  conclusively  shown,  they  may  be  semisolid  or  even 
quite  firm.  Where  they  are  fluid  or  semifluid,  the  admixture  of 
mucous  shreds,  as  well  as  the  presence  of  bile  pigment  and  of  bile- 
tinged  epithelial  cells  and  muscular  fibres,  indicate  an  affection  of 
the  small  intestine.  Where  the  evacuations  are  firm,  the  question 
of  disease  of  the  small  or  of  the  large  intestine  is  most  readily  and 
positively  answered  by  means  of  a  test  lavage  of  the  bowel.  If  the 
irrigation  repeatedly  brings  away  large  quantities  of  membranous  or 
viscid  mucus,  there  is  undoubtedly  a  catarrh  of  the  large  intestine 
present;  whether  catarrh  of  the  small  intestine  coexists  can  not  be 
determined  by  this  procedure.  If  the  test  lavage  results  nega- 
tively, the  diagnosis  is  very  difficult  in  case  the  stool  is  firm  or 
semisolid.  JS^othnagel  has  stated  that  the  presence  of  so-called 
yellow  mucous  granules  or  of  hyaline  mucous  islets  is  characteris- 
tic of  catarrh  of  the  small  intestine,  or  of  catarrh  of  the  upper- 
most portion  of  the  large  intestine  (page  96).  The  existence  of 
these  formations  has,  however,  been  denied  by  Ad,  Schmidt,  whose 
opinion  I  must  corroborate  on  the  ground  of  numerous  personal 
examinations  of  faeces. 

It  will  thus  be  seen  that,  aside  from  the  subjective  symptoms, 
which  are  for  the  most  part  uncharacteristic,  the  diagnosis  of  that 
form  of  catarrh  of  the  small  intestine  which  is  accompanied  by 
constipation  or  by  normal  dejecta,  rests  upon  the  demonstration  of 
abnormal  products — i.  e.,  unchanged  bile  pigment  (demonstrable 
either  macro-  or  microscopically),  the  constant  presence  of  exceed- 
ingly numerous  muscular  fibres,  of  well-developed  starch  cells,  of 
fat  in  the  form  of  globules  or  needles  (fatty  acids  or  fatty  soaps)  in 
the  faeces. 

As  has  been  previously  remarked,  the  localization  of  a  catarrh 
of  the  small  intestines  (duodenum,  jejunum,  ileum)  is  very  difiicult, 
and  usually  impossible.  ISTevertheless,  according  to  my  experience, 
we  occasionally  meet  with  cases  in  which  the  diagnosis  may  be  ven- 
tured.    The  following  case  is  an  illustration  : 

EmilB.,  sixty-two  years  of  age,  cabinetmaker,  has  always  been  perfectly 
healthy.  He  was  taken  ill  in  the  summer  of  1892  with  a  feeling  of  pressure  in 
the  epigastrium  and  violent  diarrhoea  (about  seventeen  evacuations  in  twenty- 
four  hours).  From  October,  1893,  to  March,  1893,  his  condition  improved.  At 
this  time  there  was  a  recurrence  of  his  diarrhoea  (four  liquid  stools  a  day),  to- 


220  DISEASES  OP  THE  INTESTINES 

gether  with  painful  sensation  of  pressure  in  the  region  of  the  stomach.  The 
patient  complained  also  of  shortness  of  breath  and  bodily  weakness.  His  con- 
dition, as  recorded  at  the  time,  was  as  follows  :  Examination  of  the  abdomen, 
negative  ;  lungs  emphysematous  ;  diffuse  bronchitis  ;  heart  dulness  partially 
obscured  by  the  lungs  ;  cardiac  sounds  clear.  Test  lavage  of  the  intestine 
yielded  numerous  large  shreds  of  mucus.  Microscopic  examination  of  faeces 
negative.  Treatment  dietetic.  Improvement.  On  July  18,  1895,  the  patient 
returned,  complaining  again  of  diarrhoea.  The  first  stool  in  the  morning  is  the 
only  one  of  a  somewhat  firm  consistency;  the  others  (six  to  ten)  are  always 
fluid.  After  the  principal  meal  there  are  always  two  to  three  stools  at  short 
intervals.  No  pain  or  tenesmus  is  present  ;  rumbling  of  the  bowels  is  felt. 
The  appetite  is  fair;  there  are  no  eructations,  no  vomiting  ;  the  diarrhoea  is  said 
to  be  unaffected  by  the  kind  of  nourishment  taken. 

Condition  on  July  18,  1895.  The  patient  is  a  well-nourished  man,  with 
a  normal  colour  of  the  skin.  The  mucous  membranes  are  somewhat  pale.  The 
lungs  are  emphysematous.  The  area  of  cardiac  dulness  is  somewhat  dimin- 
ished ;  heart  sounds  are  clear,  though  somewhat  muffled.  The  radial  artery 
rigid.  The  abdomen  is  well  rounded,  the  abdominal  muscles  tense.  There  is 
no  tumour  present,  no  tenderness,  no  splashing  sounds,  oedema,  or  eruptions  of 
the  skin.  The  urine  is  free  from  albumin  and  sugar,  but  contains  indican  in 
moderate  amount. 

The  dejections  are  fluid,  of  a  brownish-yellow  colour  ;  their  odour  is  pun- 
gently  acid,  but  not  at  all  faecal.  Reaction,  decidedly  acid.  They  give  a  posi- 
tive reaction  for  bile  pigment.  A  digestive  test  was  made  with  a  filtrate  of  the 
stool,  by  means  of  a  scale  of  albumin  (serum  albumin),  without  any  further  addi- 
tion. At  the  expiration  of  three  and  a  half  hours  the  albumin  scale  was  per- 
fectly dissolved. 

Microscopical  examination  showed  little  mucus,  much  starch  in  well-pre- 
served granules,  many  muscular  fibres,  strongly  tinged  with  bile.  Examina- 
tion of  further  specimens  of  faeces  gave  the  same  result,  excepting  that  the 
digestive  test  (with  albumin)  was  negative.  Test  lavage  of  the  large  intestine 
yielded  jellylike  mucus. 

My  opinion  that  this  case  was  one  of  catarrh  of  the  upper  por- 
tion of  the  small  intestine  (with  probable  catarrh  of  the  colon)  is 
based  upon  the  pronounced  biliary  character  of  the  brownish-yellow 
fluid  evacuations,  which  were  quite  free  from  fsecal  admixture. 
Although  the  digestion  test  only  gave  positive  results  on  a  single 
occasion — something  very  unusual  in  my  experience — yet  this,  when 
taken  in  connection  with  the  other  features  of  the  case,  serves  as  an 
additional  support  to  the  diagnosis.  As  far  as  I  have  seen,  Noth- 
nagel ^^  is  the  only  one  who  has  called  attention  to  the  peculiarities 
of  the  stools  in  such  cases,  and  to  the  difficulties  of  a  differential 
diagnosis  between  these  diarrhoeas  (jejunal  diarrhoea)  and  the  true 
catarrhs. 

Special  mention  should  be  made  of  a  form  of  dyspeptic  diarrhoea 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  221 

which  I  have  frequently  met  with,  and  which  is  of  extreme  prac- 
tical importance.  It  is  associated  with  severe  types  of  chronic 
gastric  catarrh,  such  as,  following  the  nomenclature  of  Einhorn, 
are  now  called  achylia  gastrica.  Biedert  ^^  published  minute  and 
valuable  personal  observations,  and  subsequently  Einhorn^*,  and 
especially  Oppler^^,  have  called  attention  to  this  condition.  It  is 
characterized  by  a  subsidence  of  the  subjective  gastric  symptoms 
and  the  appearance  of  chronic  intestinal  disorders,  severe  diarrhoea 
being  especially  complained  of.  As  a  rule,  while  the  motor  func- 
tion remains  intact,  the  gastric  secretion  completely  disappears. 
Examination  of  the  stools  shows  a  disturbance  in  digestion,  abun- 
dant unaltered  food  residues,  remains  of  animal  tissues,  espe- 
cially connective  tissue,  vegetable  products,  and  also,  but  less  often, 
fatty  elements  are  present.  Of  the  numerous  observations  of  this 
sort  which  I  have  collected  in  the  course  of  years  I  will  quote 
but  one,  and  that  notable  for  the  extent  of  the  functional  disturb- 
ances. 

Max  G.,  nurse,  forty-one  years  old.  Underwent  an  operation  for  hemor- 
rhoids six  years  ago,  after  which — doubtless  because  of  a  stricture  of  the  rectum 
— rectal  bougies  were  passed  for  several  weeks.  From  that  time  until  two  years 
ago  the  patient  remained  well  ;  then  he  began  to  have  occasional  attacks  of 
diarrhoea.  The  patient  denies  any,  even  slight,  gastric  symptoms  at  this  period, 
excepting  perhaps  acid  eructations.  At  all  events,  he  could  eat  any  kind  of 
food  without  discomfort.  In  the  last  two  months  the  diarrhoea  has  mark- 
edly increased,  so  that  he  now  has  four  or  five  thin  fluid  movements  each  day, 
without  tenesmus. 

Examination  of  the  abdomen  and  rectum  is  quite  negative.  On  the  other 
hand,  repeated  examination  of  the  gastric  contents  shows  absolutely  undigested 
food  with  a  good  deal  of  mucus,  and  neither  free  nor  combined  hydrochloric 
acid.  Examination  for  pepsin  gives  negative  results ;  that  for  rennet  ferment 
shows  that  only  when  undiluted  is  the  gastric  juice  capable  of  coagulating 
milk.  In  order  to  ascertain  the  digestive  capacity  of  the  intestine,  the  patient 
was  given  a  test  meal  on  the  evening  of  December  19,  1898,  consisting  of  a 
quarter  of  a  pound  of  uncooked  beef  cut  into  small  pieces.  On  the  following 
morning  the  fseces  consisted  almost  exclusively  of  undigested  meat,  particularly 
the  connective  tissue. 

At  a  second  test,  in  which  the  same  quantity  of  beef  was  given  in  minced 
form,  numerous  undigested  fragments  of  connective  tissue  were  again  found, 
and  on  microscopic  examination  a  moderate  quantity  of  muscular  fibres.  This 
stool  was  a  thin  fluid  of  brownish  colour;  its  filtrate  gave  a  flocculent  precipi- 
tate with  nitric  acid,  and  with  caustic  potash  and  sulphate  of  copper  (in  very 
dilute  solution)  a  decided  biuret  reaction.  The  examination  was  repeated  on 
several  occasions  with  the  same  result,  except  that  the  biuret  reaction  varied  in 
intensity. 


222 


DISEASES  OF  THE  INTESTINES 


This  case  is  therefore  one  of  those  which  the  older  writers  used 
to  call  lientery  {\€tov,  slippery,  and  evrepov,  bowels).  It  would  be 
difficult  to  decide  in  this  case  whether  we  have  to  deal  with  a  true 
enteritis  or  with  a  partial  atrophy,  but  doubtless  a  marked  functional 
disturbance  in  the  secretion  of  the  intestinal  glands  and  the  pancreas 
must  be  thought  of.  The  latter  feature  has  acquired  special  inter- 
est from  the  fact,  long  since  known,  but  recently  confirmed  by 
Pawlow^^  (who  has  demonstrated  it  in  a  way  worthy  of  imitation  by 
other  investigators),  that  the  hydrochloric  acid  of  the  gastric  juice 
is  the  most  important  excitor  of  pancreatic  secretion.  Thus,  if  we 
may  transfer  the  results  of  animal  experiments  to  human  physi- 
ology, a  new  light  is  shed  upon  the  origin  of  this  form  of  intestinal 
dyspepsia. 

Diagnosis  of  Cheonic  Catareh  of   the  Laege  Intestine 

In  well-marked  cases  the  diagnosis  of  uncomplicated  catarrh  of 
the  large  intestine  seldom  offers  difficulties.  The  subjective  signs 
are  essentially  those  which  depend  on  the  function  of  defecation, 
and  are  not  characteristic,  unless  it  may  be  the  tormenting  feeling 
of  pressure  or  pain,  above  mentioned,  or,  in  diarrhoeal  cases,  the 
colicky  pains,  to  which  tenesmus  may  be  added,  if  the  process  ex- 
tends to  the  lower  segments  of  the  bowel. 

The  objective  signs  consist  in  tenderness  on  pressure  and  changes 
in  the  faeces.  The  tenderness  on  pressure,  which  has  already  been 
described,  is  by  no  means  constant.  When  present,  it  seldom 
extends  over  the  entire  length  of  the  large  intestine,  but  affects 
localized  segments,  most  frequently  the  descending  colon  and  sig- 
moid flexure.  The  sensitiveness  may  be  of  various  degrees  of 
intensity ;  occasionally  even  the  slightest  pressure  is  disagreeable. 
Patients  with  well-marked  tenderness  usually  complain  of  pain  in 
the  corresponding  portion  of  the  bowel,  particularly  after  being 
seated  for  a  long  time,  or  after  walking,  bending,  or  riding,  etc. 

The  nature  and  form  of  the  mucus  evacuations  is  of  great  impor- 
tance in  determining  the  regional  extension  of  catarrh  of  the  large 
intestine.  The  lower  the  portion  affected,  the  purer  and  more 
unmixed  are  the  mucus  dejections.  Thus  the  passage  of  pure 
mucus  points  to  catarrh  of  the-  rectum,  the  sigmoid  flexure,  or  the 
lower  segment  of  the  descending  colon.  Similarly,  hard  masses  of 
fseces  coated  with  mucus  indicate  that  the  disease  is  situated  in  the 
lower  portions  of  the  bowel. 

The  examination  of  the  stools  gives  the  following  results : 


ACUTE  AND  CHRONIC   INTESTINAL  CATARRH  223 

(a)  With  Constipation. — The  stools  frequently  show  mucus 
either  gelatinous  or  in  strips  (membranes),  but  not  so  constantly  as 
after  irrigation.  In  other  respects  the  formation  may  be  normal  or 
diarrhoea],  or  of  the  consistence  of  pulp,  or  like  sheep  dung.  For 
the  microscopical  peculiarities,  see  chapter  on  the  Examination  of 
the  Fgeces. 

(b)  With  Dian'hma. — In  these  cases  the  diagnosis  as  to  localiza- 
tion is  best  reached  by  exclusion — that  is  to  say,  by  observing  the 
absence  of  unchanged  biliary  pigment.  In  other  respects  the  stools 
in  this,  as  well  as  in  the  previously  described  form,  show  only  scanty 
food  residues,  in  particular  very  little  unchanged  muscular  fibre, 
starch,  or  fat.  The  mucus  is  usually  found  intimately  mingled 
with  the  stool,  or  in  the  form  of  little  shreds  visible  when  the  vessel 
is  rotated. 

Diagnosis  of  Mixed  Foems  of  Intestinal  Cataeeh 

The  diagnosis  can  be  made  solely  from  the  peculiarity  of  the 
stools,  which  in  such  cases  are  almost  always  diarrhoeal.  As  before, 
the  recognition  of  biliary  pigment,  undigested  food  residues,  espe- 
cially muscular  fibres,  points  to  a  localization  in  the  small  intestine, 
while  the  results  of  irrigation  will  show  whether  or  not  the  large 
intestine  is  involved.  The  character  of  the  stools  as  regards  mucus 
resembles  that  of  catarrh  of  the  large  intestine. 

Although  in  the  preceding  pages  we  have  described  the  clinical 
characteristics  of  intestinal  catarrh  with  especial  reference  to  the 
determination  of  the  regional  extent  as  fully  as  our  present  knowl- 
edge permits,  we  must  not  forget  that  such  a  delineation  is  largely 
schematic.  When  we  consider  that  hypertrophic  catarrhal  pro- 
cesses are  frequently  associated  with  atrophic  changes  that  can 
not  be  diagnosticated,  that  catarrhs  may  arise  from  neurotic  con- 
ditions, that  disturbances  in  intestinal  absorption  must  be  con- 
sidered and  may  markedly  infiuence  the  clinical  picture,  we  must 
exercise  the  greatest  caution  in  expressing  an  opinion  in  those 
cases  where  the  existing  conditions  permit  of  more  than  one 
interpretation. 

Teeatment  of  Cheonic  Enteeitis 

In  the  treatment  of  primary  chronic  intestinal  catarrh,  as  in  all 
catarrhs  of  mucous  membranes,  the  same  principle  that  we  have 
insisted  upon  in  acute  enteritis  holds  good :  Protection  of  the  dis- 
eased organ. 


224  DISEASES  OP  THE  INTESTINES 

Especially  must  the  nature,  the  seat,  and  the  extent  of  the 
underlying  disease  be  considered  in  this  connection.  In  the  absence 
of  better  criteria  the  character  of  the  stools  will  serve  as  an  indi- 
cator, in  all  essential  features,  of  the  morbid  processes  going  on 
within  the  intestine. 

For  all  practical  purposes  we  are  called  upon  to  treat  but  three 
conditions :  Diarrhoea,  constipation,  and  constipation  alternating 
with  diarrhoea. 

1.  Diarrhoea 

The  most  important  part  of  the  treatment  is  to  insure  complete 
bodily  rest  and  protection.  In  the  milder  cases,  moderate  physical 
exertion  or  intellectual  work  may  be  permitted,  but  in  the  severer 
forms  these  should  be  absolutely  prohibited.  Such  patients  should 
be  put  to  hed  and  kept  there  for  at  least  several  weeks. 

Absolute  rest  in  bed  has  the  advantage  that,  once  for  all,  it  puts 
a  stop  to  the  external  influences  so  often  conspicuous  in  chronic 
diarrhoea,  namely,  cold,  wet,  mental  or  physical  exertion,  and,  above 
all,  dietetic  excesses  or  transgressions.  As  the  other  diagnostic 
and  therapeutic  procedures  are  difficult  to  carry  out  at  home,  the 
treatment — especially  of  advanced  cases — is  best  conducted  in  hos- 
pitals or  in  private  sanitaria,  in  which  dietetic  arrangements  are 
well  managed. 

During  the  stay  in  bed,  continuous  warm  fomentations  may  be 
used  with  advantage.  An  appropriate  diet  is  absolutely  essential. 
There  are  three  points  to  be  observed  :  1.  To  avoid  injurious  sub- 
stances which  might  increase  the  intestinal  catarrh.  2.  To  select 
such  nutrients  as  will  be  assimilated  in  the  particular  case.  3.  To 
combine  the  greatest  variety  of  those  nutrients  whose  physiological 
action  is  astringent  or  which  reduce  secretion — in  other  words,  those 
which  have  a  tendency  to  constipate. 

The  details  of  such  a  diet  have  been  given  in  extenso  in  the 
General  Section  (page  149).  For  those  physicians  who  have  had 
little  experience  in  prescribing  a  special  dietary,  the  follomng  may 
be  of  assistance : 

8  A.  M. — "  Eichel  cocoa "  (in  water),  one  saccharin  tablet  (or 
crystallose),  toast  and  butter  (20  to  30  grams). 
10  A.  M. — One  cup  (200  grams)  rice  gruel,  buckwheat  or  oat  grits 
in  veal  bouillon  (avoid  salt).  In  addition,  50  grams 
roasted  veal  or  beef  (scraped),  or  fried  fish  or  cold 
meat  (avoid  salt  or  strongly  pickled  ham). 


ACUTE  AND   CHRONIC  INTESTINAL  CATAHRH  225 

1  p.  M. — Soup  of  peas  or  beans  or  puree  of  oatmeal,  farina,  or 
corn  starch,  etc.  (addition  of  nutrose,  tropon,  or  eucasin 
allowed  ;  somatose  forbidden).  In  summer,  huckleberry 
soup  (with  saccharin,  if  desired).  Two  hundred  grams 
of  rice  bouillon  (avoid  rice  with  milk),^  or  farina  bou- 
illon, well  thickened  by  cooking. 

Green  vegetables  or  potatoes  in  puree  form  (50  to 
100  grams). 

Meat  and  fish  (fat  excepted),  50  to  100  grams. 
(Butter  sauce  allowed ;  cream  sauces  or  highly  seasoned 
sauces  forbidden.) 

Stewed  fruits,  with  the  exception  of  huckleberries 
and  cranberries,  forbidden. 

Custards  (corn  starch,  with  a  little  yolk  of  ^^^  and 
saccharin)  allowed.     (Avoid  fruit  juices.) 

As  beverages :  Huckleberry  wine.  Burgundy,  Cama- 
rite,  Simaruba  wane,  old  Bordeaux.    (Sweet  wines,  white 
wines,  and  effervescent  beverages  forbidden.) 
4  p.  M. — Tea  (without  milk),  with  saccharin  or  cocoa.     Cakes, 

toast,  zwieback  (with  butter). 
7  P.  M. — Strained  gruel  (oatmeal,  etc.).      Cold   or  warm   meat 
(50  grams),  toast,  butter  (20  grams). 

One  or  two  glasses  of  huckleberry  wine. 

9  P.  M. — One   glass    of   huckleberry  lemonade,f  warm,  or   hot 

mulled  wine  (saccharin),  or  tea,  with  red  wine. 

It  may  be  necessary  to  cut  out  many  articles  from  this  dietary. 
It  should  only  be  relaxed  when  the  general  and  local  conditions  are 
satisfactory,  and  the  stools  have  been  formed  for  at  least  four 
weeks  without  any  relapses  having  occurred. 

Sugar,  pastry,  milk,  organic  acids,  salt,  beer,  effervescing  bev- 
erages, cold  drinks,  and  fruit  ices  should  be  positively  avoided  for 
months,  and  in  many  cases  for  years. 

The  value  of  such  a  diet,  taken  in  connection  with  absolute  rest 
in  bed,  can  not  be  overestimated.  Indeed,  I  know  of  nothing 
which  can  replace  this  treatment.  ^Nevertheless,  in  some  cases  the 
use  of  medicines  will  be  required. 

Medicinal  Treatment. —  We  know  of  no  drug  which  will  cure 

*  As  to  avoiding  milk,  see  page  144. 

f  Huckleberry  lemonade  is  made  by  adding  one  or  two  teaspoonfuls  of  huckle- 
berry jelly  to  boiled  water. 


226  DISEASES  OF  THE   INTESTINES 

an  intestinal  catarrh^  l>ut  one  of  the  symptoms,  cliar'rh(Ba,  may 
sometimes  he  fa/oourdbly  influenced  hy  ajpjprojpriate  medication. 

There  is  nothing  to  add  to  what  has  been  said  in  the  General  Sec- 
tion (page  li9  et  seq.).  We  can  only  repeat  that  we  have  little  faith 
in  the  value  of  the  numerous  astringent  and  antiseptic  remedies 
which  have  recently  come  to  notice.  Yet  there  is  one  drug  that 
should  not  be  forgotten,  because  it  combines  a  certain  degree  of  util- 
ity with  the  absence  of  any  objectionable  feature.  I  refer  to  chalk. 
It  should  be  given  as  a  mixture  of  equal  parts  of  carbonate  of 
lime  and  phosphate  of  lime.  For  several  years  I  have  preferred  to 
treat  cases  in  which  diarrhoea  has  persisted  in  spite  of  dietary  regu- 
lation, by  giving  a  teaspoonful  of  this  powder  three  times  a  day. 

Jaworski^''^  has  recently  recommended  chalk  dissolved  in  carbon- 
ated water  for  diarrhoeal  cases.  He  uses  two  formulas,  a  stronger 
and  a  weaker,  as  follows  : 

]^   Calcii  carbon 2.0 

Calcii  salicyl 2.0 

Dissolved  in  one  litre  of  highly  charged  carbonic  water.  (Aq. 
calcii  mitior.) 

Y/,   Calcii  carbon 4.0 

Calcii  salicyl 3.0 

In  similar  sohition,     (Aq.  calcii  fortior.) 

One  half  a  glass  of  the  stronger  is  to  be  taken  fasting,  in  the 
morning,  and  a  half  glass  of  the  weaker,  three  times  a  day,  after 
meals.  In  severe  cases  Jaworski  recommends  that  the  above  be 
taken  mixed  with  a  half  glass  of  warm  Carlsbad  Sprudel  water. 

The  use  of  preparations  of  chalk  is  specially  valuable  when  there 
are  eructations  of  hydrochloric  acid,  for  here  the  sodium  prepara- 
tions are  contra  -  indicated  on  account  of  their  laxative  tendency. 
A  combination  of  the  above-mentioned  chalk  mixture  with  bis- 
muth has  been  highly  recommended.  I  prefer  the  beta-naphtholate 
(orphol).  The  following  formula  is  unobjectionable  and  appro- 
priate : 

'fy  Calcii  carbon. 

Calcii  phosph.,  ää 25.0 

Bismuthi  beta-naphthol 5.0 

M.     One  teaspoonful  three  times  a  day. 

Besides  the  preparations  of  lime  just  mentioned,  the  natural 
mineral    waters    containing   lime    are    useful    as    adjuvants    [see 


ACUTE   AND  CHRONIC  INTESTINAL  CATARRH  227 

pp.  163  and  164].  Thej  are  especially  suitable  as  table  beverages. 
I  have  often  ordered  them  (warm,  one  glass  morning  and  evening) 
with  good  results,  and  can  heartily  recommend  this  treatment.* 

Concerning  the  other  hydrotherapeutic  methods,  see  General 
Section,  page  158  et  seq. 

For  the  functional  diarrhoeas  that  occur  with  achylia  gastrica, 
Oppler  ^^  has  found  hydrochloric  acid  in  large  doses  (20  to  30  drops, 
and  even  more)  very  satisfactory. 

If  there  are  gastric  disorders,  and  especially  loss  of  appetite  with 
chronic  intestinal  catarrh,  I  particularly  recommend  the  use  of 
wine  of  calumbo  (a  dessert  glassful  three  times  a  day,  before 
meals),  or  the  fluid  extract  of  calumbo  (a  teaspoonful  three  times 
a  day,  in  a  wineglass  of  lukewarm  water  or  in  a  wineglass  of  the 
above-mentioned  solution  of  chalk). 

The  treatment  of  chronic  diarrhoeas  by  enemata  is  suitable  in 
catarrhs  of  the  colon  and  the  rectum.  In  addition  to  those  already 
described  (page  181),  I  have  seen  excellent  results  from  enemata  of 
bismuth  (a  teaspoonful  in  250  cubic  centimetres  of  water).  This  is 
analogous  to  Fleiner's  method  for  the  treatment  of  gastric  ulcer. 

2.   Constipation 

In  the  treatment  of  constipation,  bodily  and  mental  rest  may 
contribute  toward  a  good  result ;  only  in  very  severe  cases  is  abso- 
lute rest  in  bed  indicated.  Experience  shows  that  warm,  frequently 
repeated  fomentations  have  a  favourable  effect  upon  the  pain. 

The  chief  indication  to  be  met  in  catarrh  of  the  intestine  accom- 
panied by  constipation  is  the  removal  of  this  symptom  by  appro- 
priate diet.  In  all  essential  features  it  is  the  same  diet  as  that  to 
be  fully  described  in  the  chapter  on  Constipation,  but  with  this 
important  exception,  that  all  foods  which  are  rich  in  cellulose^ 
or  other  indigestible  substances,  must  be  avoided.  If,  as  is  usually 
the  case,  we  succeed  in  regulating  the  evacuations  by  the  diet,  the 
abnormal  secretion  of  mucus  gradually  disappears  without  further 
treatment  (see  chapter  on  Membranous  Enteritis).  In  these  cases 
I  do  not  believe  purgatives  should  be  given ;  indeed,  I  have  a 
suspicion  that  their  use  may  cause,  or  at  least  aggravate,  an  intes- 
tinal catarrh.     If  directions  as  to  diet  do  not  suffice,  I  recommend 

*  It  is  much  to  be  regretted  that  the  treatment  of  chronic  intestinal  catarrhs  has 
not  been  undertaken  at  the  above-mentioned  springs.  With  appropriate  installations 
for  providing  suitable  diet  (somewhat  after  the  manner  of  Carlsbad),  these  springs 
would,  in  my  opinion,  take  a  prominent  [)lace  in  the  treatment  of  intestinal  catarrh. 


228  DISEASES  OF  THE  INTESTINES 

mild  enemata  of  rape-seed  oil,  oil  of  sesame,  or  olive  oil ;  of  neutral 
soap  (5  grams  to  250  cubic  centimetres  of  water),  castor  oil,  cod- 
liver  oil,  soda,  etc.  (see  page  179).  Irrigation  for  the  purpose  of 
cleansing  the  intestine  of  mucus  is  a  very  useful  adjuvant.  The 
following  solutions  are  to  be  recommended  for  this  purpose  :  Lime 
water  (3  to  4  tablespoonfuls  to  1  litre  of  water),  carbonate  of  soda 
(1  dessertspoonful  to  1  litre  of  water),  Carlsbad  salt  (in  the  same 
proportion).  Other  desirable  agents  for  the  same  purpose  have 
been  mentioned  on  page  181. 

3.   Constipation,  alternating  with  Diarrhcßa 

The  same  principles  hold  good  as  in  the  form  just  described.  It 
is  only  necessary  to  decide  which  is  the  primary  or  predominating 
feature,  and  this  can  readily  be  ascertained  by  the  use  of  a  test  diet 
for  a  few  days. 

3.    Membranous  Enteritis 

Preliminary  Considerations. — By  membranous  enteritis,  or, 
still  better,  membranous  colitis,  we  understand  a  form  of  catarrh  of 
the  large  intestine  which  is  characterized  by  three  cardinal  symp- 
toms :  (1)  A  peculiar  mucous  formation  ;  (2)  anomalies  of  intestinal 
function  ;  (3)  painful  spasm  of  the  intestine.  In  addition,  there  are 
a  few  other  collateral  symptoms,  which,  however,  have  nothing  to 
do  with  the  clinical  picture  proper  of  the  disease. 

The  classification  of  membranous  colitis  with  chronic  enteritis 
does  not  altogether  correspond  to  the  views  which  prevail  at  the 
present  time,  especially  among  German  authors.  The  predominant 
conception  is  that  which  Siredey  ^^  seems  to  have  been  the  first  to 
advance  in  1869 — that  the  membranous  mucous  formation  was  the 
result  of  a  peculiar  secretory  neurosis.  Da  Costa  ^^,  to  whom  we 
owe  its  first  classical  description,  looked  upon  membranous  colitis  as 
of  nervous  origin.  The  German  authors,  in  so  far  as  they  have 
expressed  themselves  concerning  the  pathology  of  the  disease,  do 
not  agree,  von  Leube  ^  and  Eosenheim^^  are  inclined  to  regard  it  as 
a  neurosis  of  secretion.  Ewald  ^^  takes  a  middle  ground,  and  ISToth- 
nagel^  makes  a  sharp  distinction  between  mucous  colitis  and  mucous 
colic,  one  having  an  anatomical  and  the  other  a  functional  basis. 
The  standard  French  authors  (G.  See  2^,  Potain  ^s,  Alb.  Mathieu  '^, 
de  Laugenhagen  2^)  rather  incline  to  the  view  that  there  is  a  superfi- 
cial catarrh.  On  the  other  hand,  American  authors  (Mendelson  '^ 
Einhorn  ^^  and  others)  have  recently  laid  stress  on  the  nervous  char- 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  229 

acter  of  the  affection.  Yanni^  also  speaks  of  a  myoangioneurosis 
of  the  intestine  with  hypersecretion  of  mucus.  As  far  as  I  have 
seen,  the  latter  idea  has  made  a  deep  impression  in  medical  circles, 
and  has  had  an  undeniable  influence  upon  treatment. 

From  personal  observation  I  can  say  that  it  is  difficult  to  come 
to  a  decision.  There  are  cases  in  which  the  nervous,  restless  char- 
acter of  the  affection  is  very  prominent,  so  much  so  that  it  is  diffi- 
cult to  believe  that  it  has  a  material  basis.  On  the  other  hand, 
there  is  no  doubt  in  my  mind  that  membranous  colitis  is  frequently 
found  in  patients  who  are  not  at  all  neurotic,  or  in  whom  the  neu- 
rotic stigmata  are  positively  or  probably  the  results  of  the  disease. 
An  unprejudiced  estimate  of  the  frequency  of  the  two  groups  leads 
me  to  the  opinion  that  the  latter  predominates. 

This  much  is  certain  :  the  idea  that  membranous  enteritis  is  one 
of  the  phases  of  hysteria  or  neurasthenia  must  be  rejected  as  too 
sweeping. 

Unfortunately,  neither  experimental  pathology  (Yanni  ^,  Aker- 
lund^^)  nor  pathological  anatomy  affords  us  much  assistance  as 
to  etiology.  We  have  but  two  clinical  observations  followed 
by  autopsy — those  of  O.  Eothmann^  and  of  M.  Eothmann^l  In 
the  former,  although  the  entire  intestinal  tract  was  carefully 
examined  by  C.  Rnge,  nothing  abnormal  was  found ;  while  in  the 
second  case,  reported  by  the  younger  Rothmann,*  all  the  character- 
istic lesions  of  a  catarrh  of  the  large  intestine  were  demonstrated  by 
a  very  thorough  histological  examination.  Although  it  may  seem 
venturesome  to  draw  any  conclusion  from  two  findings  so  diamet- 
rically opposed  to  each  other,  yet  there  is  no  doubt  that  the  posi- 
tive result  has  much  greater  significance  than  the  negative  one. 

Aside  from  the  main  question  whether  we  are  dealing  with 
a  functional  or  an  inflammatory  condition,  there  are  a  number  of 
other  etiological  factors  to  be  considered.  First  of  all,  the  influ- 
ence of  habitual  constipation  must  be  emphasized.  According 
to  the  experience  of  most  authors,  habitual  constipation  is  one 
of  the  most  constant  affections  occurring  together  with  mem- 
branous enteritis.  A  few  (Ewald  ^,  Einhorn  ^9,  and  others)  call 
attention  to  an  antecedent  diarrhoea  as  a  cause.  I  have  also  seen 
such  cases,  but  only  after  the  use  of  astringent  enemata.  In  addi- 
tion, numerous  observers  (Glenard  ^,  A.  Mathieu  ^^,  Ewald  ^,  Boas  ^% 
Akerlund  ^\  de  Langenhagen  ^',  Einhorn  ^,  and  others)  have  accen- 

*  The  report  of  0.  Rothmann  does  not  state  whether  a  histological  examination 
was  made. 

IG 


230  DISEASES  OF  THE  INTESTINES 

tuated  the  relationship  between  coloptosis  and  membranous  enteri- 
tis. This  etiological  factor  has  a  certain  influence,  but  only  in  so 
far  as  it  favours  the  establishment  of  habitual  constipation. 

Attention  has  been  called  by  French  investigators  to  the  rela- 
tion between  membranous  enteritis  and  uterine  diseases  (Ozenne  % 
Letcheff  ^,  and  others) ;  but  these  observations  seem  rather  to  relate 
to  accidental  complications.  It  is  well  known,  moreover,  that  uter- 
ine diseases,  as  well  as  abnormal  conditions  of  the  adnexse,  may 
cause  constipation  by  compression  or  adhesions,  and  thus  predispose 
to  membranous  enteritis. 

Finally,  at  a  recent  date,  various  French  investigators  (A.  Ma- 
thieu  ^^,  de  Langenhagen  ^^,  Chevalier  ^)  have  laid  stress  on  a  certain 
connection  between  membranous  enteritis  and  intestinal  lithiasis. 
The  periodical  formations  of  gravel,  accompanied  by  severe  colic, 
which  had  already  been  recognised  and  which  was  recently  rede- 
scribed  by  Dieulaf  oy  ^\  are  supposed  by  Mathieu  ^^  to  be  a  constant 
feature  of  membranous  enteritis.  All  that  has  been  published  on 
this  subject  simply  goes  to  show  a  possible  coexistence  of  intestinal 
lithiasis  with  the  disease  under  consideration,  but  no  proof  has  yet 
been  offered  that  there  is  any  etiological  relation. 

Artificial  membranous  enteritis  is  a  very  important  condition, 
which  from  a  practical  standpoint  has  received  much  less  attention 
than  it  merits.  I  have  frequently  observed  it  after  enemata  of  tan- 
nin, alum,  glycerin,  and  nitrate  of  silver.  In  some  cases  the  clinical 
picture  of  membranous  enteritis  already  existed  (see  Case  lY) ;  but 
I  have  become  convinced  that  the  symptoms  may  be  kept  up  and 
increased  by  irritant  injections.  Membranous  enteritis  is  also  ob- 
served as  a  sequel  to  acute  enteritis.  It  is  doubtful  whether  this  con- 
dition is  altogether  identical  with  the  one  now  under  consideration. 

After  these  preliminary  remarks,  we  will  proceed  to 

Symptomatology  and  Diagnosis 

When  we  analyze  closely  the  description  of  the  symptoms  of 
membranous  enteritis,  as  given  by  the  most  prominent  authorities 
(Da  Costa  ^^,  von  Leyden^,  ]S"othnagel  ^^,  Kitagawa^,  Krysinski*^, 
A.  Mathieu ^^,  Germain  See^,  de  Langenhagen^''',  and  others),  we 
find  such  a  lack  of  agreement  that  the  question  arises  whether 
these  authors  are  dealing  with  the  same  affection.  In  some  of  the 
cases  it  can  be  shown  with  certainty  that  the  clinical  picture  be- 
longs essentially  to  the  group  of  colica  mucosa.  Others  are  com- 
plicated by  gastric  atony,  intestinal  prolapse,  appendicitis,  etc.     In 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  231 

still  others  uterine  complications  exist.  In  one  case,  recently  de- 
scribed by  Henschen  ^^,  larvae  of  the  fly  were  present  in  the  intestinal 
canal.  Others  were  undoubtedly  due  to  artificial  influences  such 
as  have  been  just  mentioned.  Finally,  there  are  several  cases  (Mar- 
chand  ^^,  O.  Rothmann  ^^,  Richardiere  '^'^)  which,  as  far  as  concerns 
the  bowels,  gave  no  symptoms  during  life. 

'Nor  does  this  exhaust  the  list;  it  would  take  too  long  to  allude 
to  all  of  them.  We  can  only  say  that  for  diagnostic  purposes  mem- 
branous colitis  is  sometimes  an  independent  disease,  and  sometimes 
is  found  in  conjunction  with  other  afEections.  It  is  thus  easy  to  un- 
derstand that  the  clinical  picture  presents  manifold  exceptions  and 
variations. 

I  have  thought  it  advisable,  therefore,  to  select  the  following 
from  the  large  number  of  cases  which  I  have  recorded,  and  in  con- 
nection with  them  to  discuss  the  diagnosis : 

Case  I.  A  case  of  membranous  enteritis^  with  severe  disturbances  of  nutrition, 
which  had  existed  for  many  years.     Permanent  cure. 

Mrs.  Regina  B.,  twenty-seven  years  old,  born  in  Poland,  and  for  several  years 
a  resident  of  Berlin. 

The  patient  states  that  for  seven  years  she  has  suffered  from  loss  of  appe- 
tite, eructations,  pains  in  the  stomach  after  the  ingestion  of  food,  flatulence, 
and  persistent  constipation.  For  some  time  past  enemata  have  nearly  alvpays 
been  required  to  obtain  movements  from  the  bowels,  and  the  patient  has  often 
noticed  membranous  and  tubular  masses  of  mucus  in  the  stools.  These  have 
sometimes  appeared  in  such  abundance  that  the  stools  consisted  of  almost 
nothing  but  them.  The  patient  asserts  that  during  this  period  she  was  very 
nervous  and  uneasy.  She  does  not,  however,  remember  having  had  any  marlced 
pain  immediately  before  such  mucous  stools.  At  her  first  visit  to  the  polyclinic 
(March,  1893)  she  looked  very  ill,  was  extremely  emaciated,  so  that  incipient 
phthisis  was  suspected,  but  not  confirmed  by  examination.  She  was  treated 
by  irrigations  of  the  intestine;  the  washings  frequently  showed  masses  of 
mucus,  membranes  of  mucin,  and  tubular  casts  of  various  calibres.  The  sub- 
sequent treatment  was  wholly  dietetic  ("constipation  diet"). 

Under  the  latter  treatment  and  a  course  of  waters  the  patient's  condition 
improved  materially ;  she  gained  in  weight  to  a  considerable  extent,  and  began 
to  get  a  healthy  colour. 

At  my  request  she  presented  herself  in  March,  1895,  and  again  in  February, 
1899,  for  examination;  she  stated  that  her  health  had  continued  good,  and 
that  there  was  no  longer  constipation.  Irrigation  showed  that  the  mucous 
masses  were  no  longer  present. 

Case  II.  Severe  form  of  membranous  enteritis,  complicated  by  dism^ders  of 
the  stomach  and  bladder.     Cure. 

Mrs,  B.,  widow,  Kloster  Lehnin,  near  Brandenburg,  thirty-six  years  old. 
The  patient  states  that  since  the  death  of  her  husband  and  a  sixteen  year-old 


232  DISEASES  OF  THE  INTESTINES 

daughter  she  has  been  very  nervous  and  irritable,  sleeps  badly,  complains  of 
tremor  and  spots  before  the  eyes. 

The  patient  has  suffered  from  extreme  constipation  since  childhood ;  has 
always  used  enemata  and  laxatives.  In  the  last  three  years  disorders  of  the 
stomach  have  appeared :  poor  appetite,  nausea,  but  no  vomiting,  discomfort, 
and  pressure  in  the  epigastrium.  Gradually  she  began  to  have  attacks  of  se- 
vere pain  in  the  epigastrium  after  eating,  which  came  on  even  after  a  spoon- 
ful of  milk.  This  x)ain  radiated  toward  the  sides  and  back,  and  was  more 
severe  after  food  not  easily  digested.  The  constipation  increased  so  that 
four  tablespoonfuls  of  castor  oil  and  an  enema  of  oil  produced  only  a  small 
evacuation.  There  was  marked  emaciation,  and  the  patient  was  confined  to 
bed  for  months.  In  the  winter  of  1895-96  she  first  noticed  that  after  ene- 
mata pure  mucus  was  passed,  sometimes  in  the  shape  of  little  shreds,  and 
sometimes  larger  aggregations  in  tubes  or  bands  as  long  as  half  a  metre. 
After  passing  these  the  patient  used  to  feel  better.  With  these  complaints 
there  icas  associated  pain  in  the  Uadderfrom  time  to  time,  ending  in  the  passage  oj 
a  light-coloured  tirine  of  low  density.  On  admission  to  the  clinic  in  May,  1897, 
she  complained  of  debility,  weakness  on  walking,  pains  along  the  spine,  ano- 
rexia, slight  eructations,  severe  constipation,  and  the  passage  of  mucus  in  the 
stools. 

Condition  on  admission.  May  5,  1897  (with  the  omission  of  unimportant 
features) :  Floating  kidney  on  the  right  side ;  fundus  of  the  stomach  at  the  level 
of  the  umbilicus.  Loud  splashing  sounds  in  both  iliac  fossae,  and  to  some 
extent  also  in  the  epigastrium. 

An  evacuation  followed  irrigation  of  the  intestine ;  it  resembled  sheep  dung, 
and  was  covered  with  small  shreds  of  mucus ;  it  was  small  in  quantity,  and  of 
a  brown,  or  perhaps  greenish  brown  colour. 

Palpation  of  the  abdomen  showed  that  the  left  iliac  region  was  very  tender; 
there  was  also  slight  tenderness  in  the  ejjigastric  region. 

A  second  irrigation  on  the  same  day  showed  abundant  masses  of  mu- 
cus, several  of  the  shreds  measuring  a  few  centimetres  in  length.  They  were 
white  or  yellowish  brown  in  colour,  some  membranous,  and  some  vitreous  in 
appearance. 

Repeated  irrigations  gave  the  same  result.  The  microscopical  examination 
gave  the  usual  findings.  The  stools  were  in  other  respects  normal.  Treat- 
ment: constipation  diet  and  intestinal  irrigations. 

In  spite  of  these  measures  the  constipation  was  not  entirely  relieved.  Ene- 
mata could  not  be  dispensed  with.  In  the  further  history  of  the  case  the 
pains  in  the  stomach  and  spine  disappeared  and  the  patient  gained  in  weight. 
The  abdominal  pains  were  felt  occasionally.  The  evacuations  obtained  by  ene- 
mata frequently  contained  large  shreds  of  mucus.  The  neighbourhood  of  the 
sigmoid  flexure  was  still  sensitive  to  pressure,  but  much  less  so  than  formerly. 
Treatment,  aside  from  diet,  consisted  in  pulv.  glycyrrhizse  comp.,  one  tea- 
spoonful  twice  daily. 

June  2Jf,  1898. — The  patient  now  has  regular  movements  from  the  bowels; 
the  pains  have  almost  entirely  vanished ;  weight  and  strength  have  increased. 
The  evacuations  are  free  from  mucus.  The  region  of  the  sigmoid  flexure  only 
slightly  sensitive. 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  233 

Case  III.  Membranous  enteritis,  with  severe  constipation  and  occasional 
acute  colics.     Previous  history  of  ulcer  of  the  stomach  {or  duodenum  ?). 

Mrs.  B.,  resident  of  G.,  forty-one  years  old.  In  her  nineteenth  year,  four 
weeks  after  marriage,  the  patient  suffered  from  acute  peritonitis  fgonorrhoeal 
infection  ?).  She  was  confined  to  bed  for  seven  weeks,  and  had  pains  in  the 
abdomen  for  some  time  afterward. 

As  a  girl  she  suffered  from  constipation,  which  became  worse  after  the 
attack  of  pelvic  peritonitis.  Two  years  later  she  had  an  attack  of  pleurisy  on 
the  right  side,  following  which  she  began  to  have  a  persistent  gastric  pain.  In 
the  year  1885,  after  the  appearance  of  tarry  blood  in  the  stools,  a  gastric  ulcer 
was  diagnosed.  In  1887  there  was  another  attack  of  melaena,  and  in  1890 
vomiting  of  blood.  She  underwent  von  Leube's  treatment  for  ulcer,  at 
Würzburg.  Improvement  resulted,  but  only  under  the  strictest  diet.  Mucus 
was  first  noticed  in  the  stools  in  1888,  the  bowels  being  extremely  constipated. 
The  same  fact  was  noted  during  the  treatment  for  ulcer  in  1890.  Gradually 
severe  pains  developed  on  both  sides  of  the  abdomen  at  the  level  of  the  umbili- 
cus; these  were  only  relieved  by  a  free  movement  of  the  bowels.  Sometimes 
nothing  but  mucus  was  passed,  and  at  other  times  it  was  accompanied  by  faeces. 
"When  mucus  only  was  passed  there  was  no  alleviation  of  the  symptoms.  Such 
mucous  evacuations  occurred  every  four  to  six  weeks.  In  the  intervals  mucus 
was  either  absent  or  only  found  in  small  quantity. 

Present  condition :  Sensitiveness  on  pressure  localized  at  1^  centimetres  to 
the  right  of  the  median  line  at  the  junction  of  the  middle  and  lower  thirds  of 
the  space  between  the  xiphoid  cartilage  and  the  umbilicus.  Intestinal  area 
quite  free  from  sensitiveness.  Irrigation  of  the  intestine  on  two  occasions  gave 
only  a  very  small  quantity  of  mucus. 

Case  IV.  Development  of  membranous  colitis  during  pregnancy,  tcith  severe 
pyrexia.  Normal  lcd)our.  Cessation  of  the  fever.  Continuance  of  the  colitis.  Cure 
by  producing  regular  movements  of  the  bowels. 

Mrs.  H.,  twenty -five  years  old.  The  patient,  who  was  healthy,  with  the 
exception  of  a  varying  degree  of  constipation,  suddenly  took  sick  in  the  sixth 
month  of  pregnancy,  on  June  19,  1898,  with  a  chill  and  a  fever  reaching  39.6"  C. 
[103.3°  F.].  She  complained  of  pain  in  the  lower  part  of  the  abdomen  on  the 
right  side,  which  pain  radiated  to  the  lumbar  region  and  down  the  right  leg. 
Examination  yielded  no  positive  results.  The  illness  during  the  following  four- 
teen days  presented  the  picture  of  a  septic  infection. 

In  the  beginning  of  July  the  fever  and  chills  abated,  followed  on  the  10th 
by  symptoms  similar  to  those  at  the  onset.  About  the  middle  of  the  month 
the  stools  for  the  first  time  showed  mucous  casts,  which  were  both  tubular  and 
ribbonlike,  and  10-13  centimetres  in  length. 

For  the  following  particulars  I  am  indebted  to  her  family  physician,  Dr. 
Laux,  of  Oldenburg : 

On  the  18th  of  July,  having  just  returned  after  an  absence  from  town,  I  saw 
these  evacuations  for  the  first  time.  Though  quite  fresh,  they  had  a  penetrat- 
ing odour,  as  if  in  a  state  of  decomposition,  which  was  also  suggested  by  their 
dirty,  grayish  green  colour.  By  means  of  two  or  three  large  enemata,  I  succeeded 
in  removing  more  or  less  abundant  masses  of  fjeces,  with  a  resulting  subsidence 


234  DISEASES  OF  THE  INTESTINES 

of  the  strong  odour,  and  a  return  to  the  usual  colour.  Under  this  treatment  the 
chills  and  fever  disappeared,  and  the  subjective  symptoms  improved  to  some 
degree.  On  August  1st  delivery  occurred,  setting  in  with  a  chill  and  fever,  but 
otherwise  normal  in  its  progress.  The  puerperal  period  was  uneventful.  Since 
then  there  have  been,  off  and  on,  evacuations  of  mucous  shreds,  but  finely  broken 
up  and  in  small  quantity.  On  the  day  before  such  passages  there  is  pain,  which 
is  relieved  by  the  evacuation.  Persistent  constipation  exists,  but  is  controlled 
by  enemata.  Regulation  of  the  bowels  by  constipation  diet  in  my  clinic 
resulted  in  a  complete  arrest  of  the  mucous  discharge. 

The  reported  cases  of  membranous  enteritis  show  an  extraor- 
dinary preponderance  of  the  female  over  the  male  sex.  All  the 
authors  agree  on  this  point.  Litten  foimd  80  per  cent  and  Kita- 
gawa  90  per  cent  in  women ;  Einhorn  found,  in  a  total  of  20  cases, 
2  men  and  18  women,  or  about  the  same  relation  as  the  last-named 
author.  This  is  not  surprising  when  we  consider  the  prevalence  of 
coloptosis  and  constipation  among  women. 

The  greatest  number  of  cases  of  membranous  enteritis  occur 
during  the  second,  third,  and  fourth  decades  of  life ;  it  is  only  rarely 
found  during  the  later  years  of  life,  and  rarest  of  all  in  childhood. 
A  few  cases  have  been  reported  in  the  newborn  (Longuet  ^,  Ull- 
mann^^)  and  in  the  early  years  of  childhood  (Löwenstein  ^).  1  have 
seen  a  well-marked  case  in  a  two-year-old  girl  of  very  nervous 
temperament. 

The  chief  com]3laints  of  the  patients  relate  to  disturbances  of 
the  intestinal  functions.  Constipation  is,  as  I  have  repeatedly 
said,  the  condition  in  the  majority  of  cases ;  diarrhoea  is  certainly 
atypical.  Paroxysmal  pains  are  a  very  frequent  symptom.  They 
usually  mark  the  onset  of  attacks,  and  are  of  an  exceedingly  acute 
cohcky  type,  so  that  they  often  cause  symptoms  of  collapse.  The 
attack  ends  with  the  passage  of  faeces  and  membranous  mucus,  or 
of  the  latter  alone.  The  stools  have  the  usual  appearance  of  spastic 
dejections.  These  intestinal  colics  are,  however,  by  no  means  a 
necessary  symptom ;  they  may  be  slight,  or  entirely  absent,  or 
there  may  be  colicky  pains  without  passage  of  mucus ;  or,  finally, 
membranes  may  be  passed  with  or  without  attacks  of  pain.  If  we 
are  successful  in  regulating  the  bowels,  the  painful  intestinal  spasm 
and  the  mucous  evacuations  usually  cease,  or  appear  only  occasionally 
and  to  a  limited  extent. 

Together  with  these  symptoms  there  may  be  various  other  com- 
plaints, partly  of  a  nervous  and  partly  of  an  organic  origin ;  these 
have  nothing  to  do  with  the  disease  as  such ;  they  are  nothing  but 
accessory  symptoms  or  complications. 


ACUTE  AND  CHRONIC  INTESTINAL  CATARRH  235 

In  typical  cases  the  objective  signs  are  sensitiveness  over  the 
colon  or  portions  of  it,  and  the  passage  of  mucus. 

In  the  majority  of  cases  the  sensitiveness  is  noted  over  the 
descending  colon  or  the  sigmoid  flexure ;  in  other  cases  over  the 
caecum  and  ascending  colon,  and  apparently  very  much  less  fre- 
quently over  the  transverse  colon.  This  sign  alone  is  not  character- 
istic of  membranous  colitis,  since,  as  we  have  noted  above,  it  is  met 
vfith  in  ordinary  catarrh  of  the  large  intestine ;  but  in  the  former 
affection  it  is  much  more  pronounced  than  in  simple  catarrh.  The 
tenderness  which  under  certain  circumstances  is  not  much  less  than 
in  appendicitis,  seems  to  bear  a  positive  relation  to  the  process,  for 
it  disappears  or  diminishes  as  cure  or  improvement  occurs,  to  return 
in  a  surprising  way  when  a  relapse  occurs. 

The  expulsion  of  mucus  or  membranes  is  the  most  decisive 
clinical  sign.  It  is  hardly  conceivable  that  these  formations  should 
be  mistaken  for  tapeworm,  food  residues,  etc.,  or  anything  else,  or 
that  the  affection  should  be  confounded  with  croupous  enteritis,  if 
careful  macroscopic  and  microscopic  examination  is  made.  Three 
kinds  of  mucous  formation  can  be  distinguished:  1,  unformed,  struc- 
tureless mucus ;  2,  hyaline,  tubular  formations,  which  under  cer- 
tain conditions  form  a  cast  of  the  internal  surface  of  the  intestine ; 
3,  membranous  mucus,  sometimes  firm  and  sometimes  spongy  in 
consistence.  The  chief  constituent  of  these  secretions — for  there  is 
no  doubt  on  this  point  at  the  present  day — is  mucus  and  an  albu- 
minoid body,  the  latter  depending  upon  the  varying  admixture  of 
cellular  elements.  According  to  careful  investigations  of  Kita- 
gawa^,  M.  Eothmann^,  Akerlund^^,  Ad.  Schmidt  ^^,  and  Pariser  ^2, 
there  is  no  fibrin  present,  and  they  are  thus  differentiated  from  the 
exudates  in  intestinal  diphtheria. 

In  doubtful  cases  a  microscopic  examination  is  a  useful  supple- 
ment to  the  results  of  the  macroscopic  investigation.  Even  without 
the  addition  of  acetic  acid,  but  better  with  it,  there  will  be  found 
the  peculiar  threadlike  substance  in  which  cells,  nuclei,  and  detritus 
are  embedded  in  variable  quantity.  Most  of  the  cells  have  lost  their 
characteristic  appearance  (see  Fig.  16,  page  118),  fresh,  unchanged 
cells  being  rarely  found.  Opinions  differ  as  to  the  cause  of  this 
degeneration.  J^othnagel^^  thinks  it  is  due  to  desiccation.  Kita- 
gawa  regards  it  as  a  degeneration  process  (coagulation  necrosis). 
As  Ad.  Schmidt  ^^  has  recently  shown,  it  is  due  to  an  infiltration  of 
fatty  soaps,  on  the  removal  of  which  the  cells  regain  their  bright, 
transparent  appearance.     There  are  also  found  a  greater  or  less 


236  DISEASES  OF   THE  INTESTINES 

number  of  leucocytes,  occasionallj  Charcot-Leyden  crystals,  and 
micro-organisms  of  various  kinds.  ISTone  of  these  have  any  special 
significance. 

CompKcations  are  very  frequent.  Associated  disease  of  the 
uterus  and  adnexse  and  intestinal  lithiasis  have  already  been  men- 
tioned. The  literature  of  the  subject  shows  that  albuminuria, 
pyrexia,  epileptic  attacks,  tachycardia,  dyspnoea,  neuralgia,  tremor, 
somnolence,  amblyopia,  and  melancholia  are  occasional  accompani- 
ments. Einhorn  ^  found  that  out  of  twelve  cases  achylia  gastrica 
was  present  in  five,  and  in  several  cases  the  gastric  motor  function 
was  increased. 

The  course  of  membranous  cohtis,  like  that  of  habitual  constipa- 
tion, is  exceedingly  chronic,  but  like  it,  shows  marked  remissions 
and  intermissions.  The  general  nervous  symptoms  follow  very 
closely  the  increase  or  diminution  in  the  colicky  attacks. 

The  diagnosis  of  membranous  colitis  can  be  made  in  most  cases 
from  the  symptoms  which  have  been  detailed,  especially  from  the 
results  of  repeated  intestinal  irrigation.  This  should  not  be  post- 
poned in  any  case.  It  will  show — and  I  particularly  insist  upon  this 
— that  the  membranous  formation  does  not  appear  occasionally  or 
suddenly,  but  that  smaller  or  larger  masses  of  mucous  or  tubular 
formations  may  often  be  identified  during  the  intervals  between  the 
attacks.  Some  difficulty  exists  in  the  differentiation  between  simple 
colitis  and  the  membranous  variety,  for  we  meet  with  cases  which 
might  with  equal  propriety  be  put  in  either  class.  In  general,  those 
cases  in  which  actual  membranes  are  passed  should  be  put  in  the 
present  class,  and  the  remainder  classed  with  the  other  forms  of 
enteritis.  The  other  fact  already  mentioned,  that  membranous 
enteritis  may  arise  from  artificial  causes,  must  again  be  emphasized 
and  should  always  be  borne  in  mind. 

Teeat^iext 

Until  recently  very  unfavourable  or  doubtful  results  were  ob- 
tained from  the  treatment  of  membranous  colitis,  and  at  the  pres- 
ent time  the  disease  is  frequently  obstinate,  and  yields  reluctantly 
to  therapeutic  influences.  This  is  especially  true  of  those  cases  in 
which  a  hysterical  element  is  prominent. 

In  cases  of  a  conspicuously  catarrhal  type  much  more  may  be 
expected  from  treatment. 

In  accordance  with  our  conception  of  the  nature  of  the  disease, 
chief  stress  is  to  be  laid  upon  the  treatment  of  the  enteritis,  with- 


ACUTE  AND   CHRONIC   INTESTINAL  CATARRH  237 

out  underestimating  the  importance  of  such  elements  as  neuras- 
thenia, enteroptosis,  anaemia,  or  faulty  nutrition. 

We  have  already  said,  and  it  has  been  recently  emphasized  by 
von  I^oorden^^,  that  the  chief  feature  of  the  treatment  of  mem- 
branous enteritis  consists  in  the  relief  of  the  constipation  by  an 
appropriate  diet,  von  IS^oorden^  rather  recklessly  states  that  one 
rich  in  coarse  constituents,  with  abundance  of  butter  and  fats,  is 
appropriate.  I  have  not  had  any  experience  with  this  method,  but 
I  can  not  suppress  the  thought  that  such  a  coarse  diet  may  gi'adu- 
ally  set  up  intestinal  irritation.  I  still  believe  in  the  view,  expressed 
some  time  ago  ^^,  and  repeated  recently,  that  a  constipation  diet,  with- 
out husks  or  cereals,  is  the  only  suitable  and  successful  dietary  in 
membranous  enteritis.  Einhorn  ^^  has  very  recently  taken  a  similar 
position. 

It  is  not  necessary  to  enter  here  upon  the  details  of  this  diet,  as 
it  differs  very  little  from  that  to  be  described  in  the  chapter  on  Con- 
stipation. We  agree  with  von  Noorden  as  to  the  cardinal  impor- 
tance of  an  abundant  supply  of  nutriment,  since  the  patients  are 
generally  individuals  who  are  depreciated  by  ansemia,  faulty  nutri- 
tion, or  frequent  pregnancies.  I  have  seen  excellent  results  from 
the  employment  of  forced  nutrition,  always,  of  course,  with  due 
attention  to  the  question  of  constipation. 

In  those  cases  in  which  the  constipation  is  overcome  by  diet, 
local  treatment  of  the  intestinal  tract  is  superfluous ;  in  other  cases 
it  may  be  of  advantage.  According  to  Fleiner,  enemata  of  oil  are 
very  successful,  but  I  have  not  had  sufficient  experience  with  them 
to  be  able  to  say  whether  their  effect  is  lasting.  Careful  irrigation 
with  unirritating  substances,  such  as  physiological  salt  solution,  so- 
dium carbonate,  or  Carlsbad  salt,  may  be  of  material  assistance.  On 
the  other  hand,  caution  must  be  recommended  in  the  use  of  astrin- 
gent solutions  which  are  apt  rather  to  increase  the  difficulty  (tannin, 
alum,  nitrate  of  silver,  etc.).  For  the  same  reason  I  consider  the 
stronger  purgatives  contra-indicated,  while  the  milder  laxatives,  such 
as  rhubarb,  tamarinds,  liquorice  powder,  and  preparations  of  sagrada, 
may  be  of  use  if  dietetic  measures  are  not  sufficient.  Other  drugs 
(ext.  fl.  hydrast.  canadensis,  bromids,  opiates)  have  been  recommended, 
but  a  real  influence  upon  the  morbid  process  is  hardly  to  be  ex- 
pected from  them.  Perhaps  the  painful  colics  may  be  ameliorated 
by  suppositories  containing  codeia,  belladonna,  or  opium.  In  gen- 
eral, the  continuous  or  intermittent  application  of  moist,  warm,  or 
hot  poultices,  in  connection  with  aromatic  infusions,  will  suffice. 


238  DISEASES  OF  THE  INTESTINES 

In  cases  of  membranous  colitis  with  prominent  nervous  disturb- 
ances hydrotherapeutic  procedures  are  very  valuable  (half  baths, 
shower  baths,  douches,  wet  packs,  etc.).  Change  of  air  and  a  warm 
climate  sometimes  contribute  to  a  cure.  The  mineral  waters  do  not 
promise  great  or  permanent  results. 

Among  the  curiosities  of  treatment,  I  may  mention  that  the  sur- 
geons have  attempted  to  cure  membranous  colitis  by  the  establish- 
ment of  an  artificial  anus  (Hale  White  and  Golding  Bird  ^,  F. 
Franke ^^).     They  claim  to  have  had  successful  cases. 


LITERATURE 

1.  Gaffky.     Deutsch,  med.  Wochenschr.,  1893,  No.  74. 

2.  Kjellberg.     Nordiskt  med.  Axkiv,  1869,  Bd.  i. 

3.  Hermann.     Wiener  med.  Wochenschr.,  1890,  S.  1044. 

4.  Mühlhäuser.     Berliner  klin.  Wochenschr.,  1873,  S.  595. 

5.  Kobler.     Wiener  klin,  Wochenschr.,  1890,  No.  28-31. 

6.  Fischl.     Prager  Vierteljahrsschrift,  1878,  Bd.  cxxxix,  S.  37. 

7.  Stiller.     Wiener  med.  Wochenschr.,  1890,  No.  78  u.  79. 

8.  Turner.     Practitioner,  October,  1894. 

9.  Strümpell.     Lehrbuch  d.  spec.  Pathologie  u.  Therapie,  Bd.  i,  1883,  S.  565. 

10.  Fleischer.     Krankheiten  d.  Speiseröhre  d.  Magens  u.  Darmes,  S.  1336. 

11.  Nothnagel.     Darmkrankheiten,  S.  98. 

13.  Nothnagel.      Beiträge  zur  Physiologie  u.  Pathologie  d.   Darms.      Berlin, 
1884,  S.  191. 

13.  Biedert  und  Langermann.     Diätetik  u.  Kochbuch.     Stuttgart,  1895. 

14.  Einhorn.     Archiv  f.  Verdauungskrankheiten,  Bd.  i,  S.  158,  1895. 

15.  Oppler.     Deutsch,  med.  Wochenschr.,  1896,  No.  33. 

16.  Pawloff.     Die  Arbeit  d.  Verdauungsdrüsen.     Wiesbaden,  1898. 

17.  Jaworski.     Therapeutische  Monatshefte,  1898,  Heft  3. 

18.  Siredey.     Union  medicale,  1869. 

19.  Da  Costa.     Amer.  Jour.  of  the  Medical  Sciences,  p.  331,  1871. 

30.  von  Leube.     Specielle  Diagnose  innerer  Krankheiten,  1889,  S.  370. 

31.  Rosenheim.     Pathologie  u.  Therapie  d.  Krankheiten  d.  Darms,  1893,  S.  133. 

33.  Ewald.     Nineteenth  Century  Practice  of  Medicine,  1897,  p.  365. 
23.  Nothnagel.     Darmkrankheiten,  S.  139. 

34.  G.  See.     Bullet,  medic,  1893,  p.  1167. 

35.  Potain.     Semaine  medicale,  1887,  p.  341. 

26.  Alb.  Mathieu.     Gaz.  des  hopitaux,  1894,  37  Oct.     Cfr.  also  Therapeutique 
des  maladies  de  l'intestin.     Paris,  1895. 

37.  de  Langenhagen.     Semaine  medicale,  1898,  No.  1. 

38.  Mendelson.     New  York  Med.  Record,  Jan.  30,  1897. 

39.  Einliorn.     Archiv  f.  Verdauungskrankheiten,  Bd.  Iv,   Heft  4,    1898,    and 

New  York  Med.  Rec. 

30.  Vanni.     Rivista  clinica,  1888,  No.  4. 

31.  Akerlund.     Archiv  f.  Verdauungskrankheiten,  Bd.  i,  S.  396,  1895. 


ACUTE  AND  CHRONIC  INTESTINAL   CATARRH  £39 

32.  O.  Rothmann.     Deutsch,  med.  Wochenschr. ,  1887,  No.  27. 

33.  M.  Rothmann.     Zeitschr.  f.  klin.  Medicin,  1893,  Bd.  xxii. 

34.  Ewald.     Deutsch,  med.  Wochenschr.,  1893,  No.  41, 

35.  G16nard.     De  l'Entöroptose,  1889. 

36.  Boas.     Deutsch,  med.  Wochenschr.,  1893,  No.  41. 

37.  Ozenne.     Journal  de  Medecine,  31  Dec,  1893. 

38.  LetchejBf.      De  la  colite  muco-membraneuse  chez  les  uterines.     These  de 

Paris,  1895. 

39.  Alb.  Mathieu.     Soc.  medic,  des  h6pit.,  22  Mai,  1896. 

40.  Chevalier.     Contribution  ä  l'etude  de  la  lithiase  intestinale.     Paris,  1898 

(with  literature). 

41.  Dieulafoy.     Presse  medic,    1895,    10  Mars  ;  and  Acad.  medic,  1897,   23 

Mars. 

42.  von  Leyden.     Deutsch,  med.  Wochenschr.,  1882,  No.  16  u.  17. 

43.  Kitagawa.     Zeitschr.  f.  klin.  Medicin,  Bd.  xviii,  1890. 

44.  Kryainski.     Enteritis  membranacea.     Inaug. -Dissert.,  Jena,  1884, 

45.  Henschen.     Wiener  klin.  Rundschau,  1896,  No.  33. 

46.  Marchand.     Berliner  klin.  Wochenschr.,  1877. 

47.  Richardiere.     Union  medicale,  1895,  No.  1. 

48.  Longuet,     Rec  de  mem.  de  med.  milit ,  1878, 

49.  Ulimann,     Deutsch,  med.  Wochenschr.,  1894,  No.  2. 

50.  Löwenstein.     Ibid.,  1889,  No.  2. 

51.  Ad.  Schmidt.     Zeitschr.  f.  klin.  Medicin,  Bd.  xxxii,  Heft  3  u.  4,  1897. 

52.  Pariser.     Deutsch,  med.  Wochenschr.,  1893,  No.  41. 

53.  von  Noorden,     Zeitschr.  f.  prakt.  Aerzte,  No,  1,  1898. 

54.  Boas,     von  Leyden's  Handbuch  d,  Ernährungstherapie,  1898,  Bd,  ii,   Ite 

Abth.,  S,  309. 

55.  Haie  White  and  Golding  Bird.     Clinical  Society,  1896. 

56.  F.  Franke,     Mittheilungen  aus  d.  Grenzgebieten,  etc.,  Bd,  i,  1896,  S.  379. 


CHAPTER  XIY 

HABITUAL    CONSTIPATION.     DISPLACEMENTS  OF  TEE 
INTESTINES* 

A.     HABITUAL    CONSTIPATION 

Preliminm^y  Remarks. — By  habitual  constipation  we  understand 
a  condition  in  which  the  intestine  irregularly  or  incompletely 
evacuates  its  contents.  An  estimate  of  the  normal  frequency  of 
defecation  is  intentionally  omitted  from  this  definition,  for  this  may 
be  greater  or  less  without  giving  rise  to  a  morbid  condition.  Every 
physician  of  experience  knows,  and  every  text-book  of  special  pa- 
thology mentions,  examples  of  extraordinary  infrequency  of  defeca- 
tion without  disturbance  of  health.  Less  known  and  appreciated, 
and  doubtless  not  so  common,  is  the  physiological  occurrence  of 
the  opposite  condition — that  is,  an  unusual  frequency  of  defecation, 
the  stools  being  otherwise  normal.  Of  this  I  have  observed  several 
examples. 

There  is  a  sharp  line  to  be  drawn  between  this  condition  and 
morbidly  retarded  defecation  with  its  train  of  consequences.  The 
latter  is  sometimes  an  acute  and  sometimes  a  chronic  condition  ;  it 
may  be  artificial,  or  it  may  result  from  alimentary  causes ;  occasion- 
ally it  accompanies  or  is  the  sequel  of  other  not  wholly  intestinal 
disorders  ;  finally,  it  may  be  idiopathic,  or,  to  speak  more  accurately, 
be  independent  of  any  recognisable  organic  cause. 

Of  the  forms  just  mentioned,  alimentary  constipation,  on  account 
of  its  great  practical  importance,  deserves  a  few  remarks.  It  owes 
its  origin,  no  doubt,  to  a  perverted  or  insufficient  diet.  It  is  specially 
observed  among  the  higher  classes  where  there  exists  a  very  obstinate 
traditional  preference  for  what  is  called  a  "  nourishing  diet "  (meat 
and  fish),  or,  in  general,  for  very  easily  digested  food.     Deficient 


*  lUoway :    Constipation  in  Adults  and  Children,  New  York,  1897,  is  a  very- 
useful  and  complete  monograph  on  constipation,  which  we  can  recommend  to  the 
reader  who  is  interested  in  details. 
240 


HABITUAL  CONSTIPATION  241 

bodily  exercise  and  work  is  often  an  associated  cause.  Further  fac- 
tors consist  in  irregnlarity  of  life  in  every  sense — in  time  of  meals, 
of  sleep,  of  work,  and,  of  course,  in  the  act  of  defecation  itself. 

As  a  secondary  condition,  habitual  constipation  is  found  in  con- 
nection with  a  great  variety  of  diseases  belonging  to  every  depart- 
ment of  medicine  and  surgery,  and  no  attempt  will  be  made  to 
enumerate  them.  Constipation,  as  a  complication  or  sequel  of  other 
intestinal  affections,  will  be  treated  of  under  the  headings  of  these 
affections. 

As  to  the  other  form  of  habitual  constipation,  that  to  which,  in  a 
strict  sense,  Nothnagel^  applies  this  term,  it  is  difläcult  to  decide 
whether  it  is  due,  as  he  supposes,  to  a  functional  abnormality  of  the 
intestinal  nervous  apparatus ;  or,  as  Emminghaus  ^  has  recently  an- 
nounced on  the  basis  of  careful  histological  research,  to  changes  in 
the  splanchnics;  or  how  far  the  condition  is,  according  to  Dunin^, 
one  of  the  features  of  anomalies  of  the  central  nervous  system 
(neurasthenia,  hysteria) ;  or,  finally,  as  Glenard  *  has  endeavoured 
to  show,  whether  it  is  dependent  upon  displacements  of  the  intes- 
tines (enteroptosis). 

It  must  be  admitted  that  each  of  these  hypotheses  has  a  basis  in 
clinical  experience,  but  no  single  one  will  serve  to  explain  the  mani- 
fold varieties  met  with  in  daily  practice.  As  Dunin  has  elucidated 
in  his  excellent  paper,  there  is  evidently  in  many  cases  a  vicious 
circle,  which  when  well  developed  may  obscure  the  initial  cause  of 
the  malady.  For  illustration,  let  us  suppose  a  case  such  as  we  see 
almost  every  day,  A  woman  who  has  previously  been  healthy  be- 
gins to  suffer  from  constipation  and  uses  laxatives ;  gradually  these 
lose  their  effect,  and  defecation  becomes  more  and  more  difficult 
and  less  complete.  Hand  in  hand  with  this  goes  a  failure  of  nutri- 
tion, either  as  a  result  of  the  abuse  of  laxatives  or  from  therapeutic 
measures  (an  "  easily  digested  diet "),  or  as  a  result  of  the  general 
failure  of  health  or  of  anaemia  or  gastric  disorders  (atony,  for  ex- 
ample). The  natural  result  is  emaciation,  prolapse  of  the  viscera, 
and  with  it  increase  of  the  constipation,  and  finally,  as  the  climax 
of  all  these  symptoms,  the  clinical  picture  of  well-marked  neuras- 
thenia. 

Every  one  of  experience  will  recognise  that  in  this  case  the  en- 
teroptosis is  not  the  cause  but  the  result  of  the  habitual  constipa- 
tion, and  the  same  is  true  of  the  neurasthenia.  On  the  other  hand, 
emaciation  from  any  cause  may  lead  to  prolapse  of  the  viscera  and 
thus  cause  constipation,  or,  more  accurately  speaking,  favour  it;  and 


242  DISEASES  OP  THE   INTESTINES 

in  this  manner,  as  Dunin  had  in  mind,  pure  neurasthenia  may  lay 
the  foundation  for  the  most  obstinate  kind  of  constipation. 

Sympto^^tatology  and  Diagnosis 

Habitual  constipation  occurs  in  several  grades  of  severity  and 
in  several  clinical  forms,  the  differentiation  between  which  is  of 
practical  importance. 

"We  may  distinguish  the  mild,  medium,  and  severe  types.  But 
what  do  we  understand  by  this  ?  That  a  certain  accord  exists 
between  the  duration  and  intensity  of  the  disease  is  undeniable,  and 
this  would  be  a  good  diagnostic  test  if  experience  did  not  show  that 
there  are  many  exceptions.  In  patients  who  have  become  con- 
stipated from  any  cause,  the  condition  may  in  a  very  short  time 
run  an  obstinate  course,  and  be  very  rebellious  to  treatment.  Nev- 
ertheless, the  duration  of  the  disease,  as  well  as  the  existence  of 
an  unmistakable  hereditary  or,  perhaps  more  accurately,  a  family 
tendency  which  has  shown  itself  in  the  development  of  the  con- 
dition in  early  childhood,  has  a  significance  not  to  be  underesti- 
mated. 

As  previously  mentioned,  I  have  found  that  we  can  judge  of 
the  intensity  of  the  process  by  the  results  obtained  from  the  usp 
of  purgatives.  When  the  most  severe  drastics,  used  in  large  doses 
for  years,  fail  to  produce  their  effect,  it  is  safe  to  assume  that  the 
case  is  a  severe  one,  and,  from  a  therapeutic  standpoint,  not  a  very 
promising  one. 

In  badly  neglected  cases,  especially  in  women,  the  faecal  accu- 
mulations may  form  tumours.  These  are  sometimes  situated  in 
the  large  intestine,  usually  in  the  csecum  or  the  neighbourhood 
of  the  sigmoid  flexure,  and  may  cause  the  outline  of  the  intestine 
to  stand  out  in  relief ;  or  they  may  be  located  in  the  rectal  pouch 
and  attain  such  a  size  as  to  dilate  the  latter  like  an  aneurismal 
sac.  It  is  well  known  that  fsecal  tumours  may  exist  and  yet  the 
defecation  be  apparently  normal  or  even  diarrhoeal  in  character,  a 
byway  having  been  formed  through  which  the  dejections  pass. 
Under  certain  unfavourable  circumstances  symptoms  of  obstruction 
which  may  require  surgical  intervention,  may  develop.  These  cases 
will  be  discussed  in  the  chapter  on  Intestinal  Stenosis. 

Yery  convenient  for  clinical  purposes  is  Fleiner's^  division  into 
two  classes,  the  atonic  and  the  spastic  forms.  My  own  experience 
would  lead  me  to  add  a  third,  which  might  be  called  the  fragmen- 
tary. 


HABITUAL  CONSTIPATION  243 

The  atonic  variety  is  the  usual  form  of  constipation  that  depends 
upon  simple  weakness  of  the  intestine,  such  as  usually  develops 
under  improper  habits  of  living  and  eating.  According  to  Fleiner, 
the  stools  are  drier  and  firmer  than  usual,  and  consist  of  compressed 
and  desiccated  lumps  or  cylinders  of  large  calibre,  or  of  distinct 
particles  or  scybalse  bearing  the  impress  of  the  sacculations  of  the 
colon. 

The  spastic  form  is  due,  according  to  Fleiner,  to  the  retention 
of  firm  masses  of  ffeces  within  segments  of  spastically  contracted 
intestine,  somewhat  as  in  lead  colic.  It  is  found  chiefly  in  neuras- 
thenics, hypochondriacs,  and  in  women  with  pelvic  disorders.  The 
stools  have  the  following  characteristics  :  long  or  short  cylinders 
of  small  calibre,  often  no  thicker  than  a  pencil  or  the  little  finger, 
or  spherical  masses  of  faeces  of  the  size  of  a  hazel  nut.  The  latter 
formation  is  not  characteristic  of  spastic  constipation,  as  it  is  also 
found  in  the  atonic  form ;  it  is  only  when  constantly  present  that 
it  is  significant. 

I  can  confirm  Fleiner's  observation  that  there  are  numerous 
transition  forms  and  combinations,  and  that  both  varieties  may  be 
associated  with  catarrh  of  the  large  intestine. 

As  I  have  said,  my  experience  leads  me  to  distinguish  a  third 
form,  fragmentary  evacuation^  on  account  of  the  peculiar  subjec- 
tive and  objective  symptoms. 

These  patients  have  regular  spontaneous  movements  of  the 
bowels,  but  the  evacuations  are  incomplete,  and  therefore  the  call 
to  defecation  is  frequently  repeated.  They  are  obliged  to  go  to 
stool  every  two  to  three  hours,  and  each  time,  with  great  straining, 
pass  small  quantities  of  cylindrical,  or  pointed,  spherical,  or  pulpy 
fgeces.  The  patients  may  have  a  sense  of  pressure  and  tenesmus 
in  the  rectum,  or  complain  of  a  feeling  of  fulness  in  the  abdomen, 
so  that  they  make  renewed  attempts  to  empty  the  bowels,  which 
may  result  in  the  evacuation  of  more  of  such  fragments,  or  be  quite 
fruitless.  This  variety  seems  to  be  especially  frequent  in  men,  and 
depends,  I  believe,  upon  a  sluggishness  of  the  lower  segments  of 
the  large  intestine,  or  sometimes  of  the  rectum  alone.  On  palpa- 
tion the  latter  may  be  found  full  of  faeces  shortly  after  one  of  these 
evacuations. 

Although  this  form  may  merge  into  the  others  or  be  combined 
with  them,  yet  I  think  it  is  entitled  to  separate  recognition  on 
account  of  its  significant  symptoms. 

The  -following  case  is  a  good  example  of  fragmentary  stools  : 


244  DISEASES  OP  THE  INTESTINES 

Paul  P.,  merchant,  of  Berlin,  thirty-nine  years  old.  Has  been  somewhat 
nervous  ever  since  academic  and  university  study.  He  suffers  frequently  from 
neuralgias,  nervousness,  and  praecordial  distress.  When  he  takes  physical  and 
mental  rest  there  is  temporary  improvement.  At  the  present  time  he  complains 
chiefly  of  intestinal  symptoms.  He  has  six  to  eight  movements  of  the  bowels 
daily.  Each  time  the  evacuations  are  small,  and  of  either  firm  or  pulpy  con- 
sistence. Defecation  is  preceded  by  an  uncontrollable  tenesmus.  No  mucus 
or  blood  in  the  stools.  The  evacuations  which  occur  during  the  night  are  espe- 
cially troublesome.  There  is  a  marked  sense  of  hunger  after  each  passage. 
Examination  of  the  intestines,  particularly  of  the  rectum  and  of  the  stools, 
shows  nothing  abnormal. 

A  prominent  symptom  of  habitual  constipation,  particularly  of 
the  spastic  form,  is  intestinal  colic.  Attacks  of  most  violent  abdom- 
inal pain  occur  with  or  without  noticeable  meteorism.  They  some- 
times involve  the  entire  abdomen,  and  sometimes  only  limited  areas, 
occasionally  lasting  for  hours,  and  subsiding  suddenly  after  the  ex- 
pulsion of  much  gas .  or  an  evacuation  of  fseces.  These  colics  are 
present  not  only  in  constipation,  but  also,  though  less  frequently, 
when  the  bowels  move  regularly.  Perhaps  in  the  latter  case  the 
evacuations  are  incomplete.  Nothnagel  *  has  also  called  attention 
to  this  fact. 

In  habitual  constipation  Kobler®  finds  that  albuminuria  or  cyl- 
indruria  are  not  infrequently  found  ;  with  the  cessation  of  the  intes- 
tinal symptoms  they  vanish. 

The  question  already  briefly  discussed,  as  to  the  relationship 
between  habitual  constipation  and  certain  cerebral  manifestations — 
such  as  headache,  sense  of  pressure  in  the  head,  psychic  depression, 
which  we  designate  at  the  present  day  by  the  comprehensive  term 
neurasthenia — can  be  disposed  of  in  a  few  words. 

An  unprejudiced  consideration  leads  us  to  divide  the  patients 
into  three  groups  :  (1)  Severe  intestinal  hypochondriacs,  whose  every 
thought  and  aspiration  is  centered  upon  the  function  of  defecation ; 
(2)  neurasthenics,  in  whom  the  constipation  is  but  one  of  many 
complaints ;  and  (3)  individuals  who  either  have  no  nervous  dis- 
orders, or  complain  of  nothing  more  than  a  sense  of  pressure  in 
the  head,  or  pain,  or  mild  general  malaise.  In  my  experience,  the 
last-mentioned  category  includes  the  great  majority  of  cases.  This 
alone  would  show  that  clinical  observation  does  not  give  support 
to  the  trend  of  the  doctrine  of  auto -intoxication  which  was  ad- 
vanced  by  Yötsch'''  in  the  TO's,  and   during  the  last  decade  by 

*  Loc.  cit.,  p.  34. 


HABITUAL   CONSTIPATION  245 

Eouchard  ^  Feyat  ^,  Glenard  \  and  others.  I  may  say  that  1  have 
been  able  to  permanently  cure  the  constipation  in  a  large  number  of 
neurasthenics  and  constipation-hypochondriacs,  but  the  symptoms 
-of  neurasthenia  do  not  vanish,  and  the  attention  is  merely  diverted 
to  some  other  disturbance. 

The  diagnosis  of  habitual  constipation  seems  at  first  sight  to  be 
an  easy  one.  This  is  a  great  error.  I  feel  bound  to  state  that  in 
the  early  years  of  my  practice  I  used  to  make  a  number  of  mistakes 
in  this  direction.  First  of  all,  the  rule  must  be  laid  down  that  when 
.simple  constipation  is  complained  of  a  thorough  general  and  local 
examination  should  never  be  omitted.  Under  the  latter  head  rectal 
examination  is  certainly  included,  especially  with  reference  to  the 
presence  of  hemorrhoids,  tumours,  fissures  of  the  anus  or  of  the 
neighbouring  integument,  which,  together  with  anomalies  of  the 
genital  tract,  hypertrophy  of  the  prostate,  tumours  of  the  uterus 
or  of  the  ovaries,  retroflexions,  etc.,  are  often  important  etiological 
factors.  In  the  General  Section  we  have  already  spoken  (page  T6) 
of  the  frequent  blunders  made  when  fsecal  tumours  are  present,  and 
we  have  pointed  out  how  these  errors  may  be  avoided.  But  aside 
from  such  mistakes,  which  can  almost  always  be  avoided  by  careful 
examination,  there  are  severe  affections  of  the  intestines  which  may 
be  concealed  under  the  guise  of  simple  habitual  constipation.  These 
are,  first,  stenoses  of  the  intestine  of  benign  character ;  secondly, 
istenosing  intestinal  carcinomata.  These  cases,  obscure  in  their  early 
.stages,  but  later  often  revealed  in  a  sudden  and  very  disagreeable 
manner,  will  be  described  under  their  appropriate  headings.  The 
following  remarks  are  limited  to  a  few  points  of  practical  impor- 
tance. 

Individuals  of  or  beyond  middle  age,  who  have  previously  been 
healthy  and  never  have  had  any  intestinal  trouble,  and  who  without 
appreciable  cause  begin  to  suffer  from  habitual  constipation,  should 
a  priori  be  suspected  of  having  intestinal  stenosis  (usually  mahg- 
nant).  This  suspicion  is  strengthened  if  there  is  progressive  ema- 
ciation. The  occasional  occurrence  of  attacks  of  coUc  should  attract 
immediate  attention.  In  such  cases,  even  in  the  absence  of  a  tumour 
that  can  be  felt,  the  chain  of  evidence  is  very  nearly  complete,  and 
it  only  remains  to  recognise  the  objective  signs  of  stenosis  by  care- 
ful clinical  observation. 

Next  to  these  most  frequent  and  dangerous  mistakes,  a  perma- 
nent and  severe  grade  of  obstruction  may  be  caused  by  adhesions 
between  coils  of  the  intestine,  incomplete  volvulus,  chronic  invagina- 
17 


246  DISEASES   OF   THE   INTESTINES 

tion,  etc.     It  will  suffice  to  mention  them  here,  as  they  will  be  dis- 
cussed in  the  chapter  on  Intestinal  Stenosis. 

It  is  undoubtedly  of  importance  to  distinguish  between  a  con- 
stipation arising  from  insufficiency  of  the  muscular  coat  of  the 
intestine  and  that  of  catarrhal  origin.  These  can  usually  be  diifer- 
entiated  from  each  other  by  inflation  and  methodical  fiUing  of  the 
intestine  with  water  in  one  case,  and  by  intestinal  irrigation  in  the 
other.  The  methods  by  which  these  may  be  accomplished  do  not 
differ  essentially  from  those  described  in  the  General  Section  and 
in  the  chapter  on  Enteritis. 

Tkeatment 

The  therapeutic  problem  in  habitual  constipation  is  that  of 
inducing  regular  and  adequate  evacuations  of  the  bowels.  It  should 
not  be  considered  solved  until  the  bowels  move  regularly  without 
the  assistance  of  mechanical  or  medicinal  co-operation,  the  diet 
being  normal  or  nearly  so.  The  ways  in  which  this  may  be  accom- 
plished are  numerous,  and  it  seems  to  me  that  the  energy  and  con- 
sistency with  which  any  one  of  these  is  carried  out  counts  for  more  in 
obtaining  a  good  result  than  the  particular  method  itself. 

Sometimes,  when  one  method  or  another  fails,  several  methods 
may  very  often  be  combined,  and  we  do  not  doubt  that  in  this  way 
also  something  may  be  accomplished.  In  everyday  practice  such  a 
procedure  may  indeed  be  justifiable,  for  the  physician  takes  what  is  of 
advantage  from  any  source ;  but  from  a  scientific  standpoint  I  must 
utter  a  protest  against  superfluous  confusion  of  therapeutic  methods. 

In  the  introductory  chapter  of  his  Guide  to  Clinical  Thera- 
peutics, Penzoldt  ^^  has  very  justly  remarked  that  a  combination  of 
methods  makes  the  estimation  of  the  value  of  any  one  of  them 
extremely  difficult.  When  a  good  result  has  been  obtained,  it  is  not 
clear  which  has  been  the  active  or  most  active  agent,  and  too  much 
credit  or  discredit  may  l)e  attributed  to  one  or  the  other.  Unsuc- 
cessful results  may  be  due  to  neglect  or  omission  of  the  essential 
feature  while  the  patient  is  occupied  with  what  is  of  no  importance. 
Besides  all  this,  a  multiplicity  of  methods  or  therapeutic  procedures, 
such  as  are  observed  in  certain  lay  hygienic  establishments  as  well  as 
in  some  managed  by  physicians,  is  by  no  means  necessary  for  the 
patient;  he  returns  from  them  loaded  with  a  confusion  of  false 
ideas,  which  are  difficult  to  eradicate  by  the  authoritative  opinion  of 
medical  men.  I  think  it  proper  to  allude  to  this  subject — which  is 
equally  pertinent  in  other  disorders  than  chronic  constipation — as  a 


HABITUAL  CONSTIPATION  247 

warning  against  the  danger  of  the  various  physical  or  mechanical 
fads  which  have  begun  to  mark  the  reaction  against  the  abuse  of 
prescription  writing. 

The  methods  for  the  treatment  of  chronic  constipation  which 
will  be  considered  are  the  prophylactic,  the  dietetic,  the  mechan- 
ical, the  electrical,  the  thermic,  and  the  medicinal. 

1.  The  p'rophylactic  treatment  of  constipation,  which  I  know 
to  be  too  Httle  appreciated,  should  begin  in  childhood,  and  consist 
in  appropriate  rules  for  the  child.  It  is  the  mission  and  the  duty 
of  parents  to  supervise  the  intestinal  activity  of  children,  to  teach 
them  to  have  evacuations  at  a  set  time,  and,  when  necessary,  to 
modify  the  diet  under  medical  advice  until  such  movements  are 
satisfactory.  The  habitual  use  of  laxatives  during  the  first  few 
years  must,  as  has  already  been  said  (page  190),  be  prohibited. 
Such  measures  are  especially  necessary  in  families  which  have  an 
inherited  tendency  toward  atony  of  the  intestine.  It  is  hard  to 
exaggerate  the  importance  of  prophylaxis  during  pregnancy,  a 
condition  which  experience  teaches  us  is  often,  chiefly  on  account 
of  the  local  conditions,  associated  with  more  or  less  constipation. 
In  these  cases  it  is  to  be  combatted  by  appropriate  food  (see  below), 
and,  as  von  Wild"  has  urged  in  his  excellent  essay,  by  gymnastic 
exercises,  so  as  to  endeavour  to  increase  the  strength  of  the  abdom- 
inal muscles.  The  same  is  true  of  pareses  due  to  long  rest  in  bed 
during  infectious  diseases  or  after  operations,  etc. 

2.  The  Diet. — We  have  discussed  the  essential  principles  of  a 
rational  diet  in  chronic  constipation  in  the  General  Section  (see  page 
146  et  seq.).  These  will  suffice  for  the  preparation  of  suitable  special 
dietaries.  Detailed  and  very  appropriate  diet  schemes  have  been 
given  by  Penzoldt  ^^,  Kosenheim  ^^,  and  Wegele  '*.  We  prefer  that  of 
Penzoldt,  because  it  is  very  simple  and  practical : 

7  A.  M.  — A  glass  of  cold  water. 

8  A.  M. — A  liberal  breakfast,  with  sweetened  coffee,  a  good  deal 

of  butter,  honey,  and  Graham  bread  or  pumpernickel, 

after  which  the  patient  should  go  to  stool. 
1  p.  M. — Midday  meal  of  meat,  a  good  deal  of  vegetables,  salad, 

stewed  fruits,  farinaceous  food,  half  a  bottle  of  light 

wine  (Moselle,  or  cider). 
7  P.  M. — Meat,  with  a  good  deal  of  butter ;  Graham  bread,  stewed 

fruit,  and  beer. 
10  p.  M. — Before  retiring,  fresh  or  stewed  fruit. 


248  DISEASES  OP  THE  INTESTINES 

The  dietaries  of  Rosenheim  and  Wegele  differ  from  the  above 
in  that  they  add,  once  or  twice  a  day,  300  grams  of  buttermilk  or 
kefir,  which  in  severe  cases  increases  the  effect  of  the  diet. 

In  the  great  majority  of  cases  a  permanently  good  result  is 
obtained  by  the  use  of  this  method — that  is,  without  systematic  adher- 
ence to  the  above  regime  the  bowels  will  move  under  the  usual  diet, 
provided  it  is  rich  in  carbohydrates.  Even  in  older,  indeed  in  very 
chronic  cases,  contrary  to  my  prognostication,  I  have  seen  very  ex- 
cellent results  from  the  use  of  this  simple  constipation  diet.  Some 
cases  soon  have  a  relapse,  partly  because  the  patient  is  not  persistent 
enough,  and  partly  because — as  in  the  case  of  medicinal  agents — 
dietetic  laxatives  may  lose  their  effect  after  a  time.  In  the  latter 
cases,  which  in  my  experience  are  certainly  unusual,  supplementary 
measures  must  be  employed. 

It  may  not  be  superfluous  to  remark  that  the  diet  above  described 
is  only  suitable  for  uncomplicated  cases  of  chronic  constipation. 
When  complications  exist  it  can  not  be  used,  or  must  be  materially 
modified.  For  example,  this  diet  is  obviously  contra-indicated  in 
diabetes  mellitus,  in  obesity,  or  in  a  tendency  thereto,  and  in  well- 
developed  alimentary  glycosuria.  The  discomforts  which  it  occa- 
sions (pyrosis,  oppression,  vomiting,  pain,  hemorrhages,  etc.)  in 
gastric  atony,  hyperacidity,  ulcer  of  the  stomach,  gastric  dilatation, 
carcinoma  of  the  stomach,  carcinoma  of  the  intestine,  etc.,  naturally 
will  forbid  its  use  in  these  conditions.  Undue  flatulence  may  con- 
tra-indicate  such  a  large  quantity  of  sweets  and  acids.  A  careful 
choice  of  the  foods  which  are  well  tolerated,  as  shown  by  prudent 
variations  and  experiments,  will  accomplish  the  desired  results.  It 
would  lead  us  too  far  to  go  into  particulars  with  reference  to  all  the 
considerations  in  question. 

Everyday  experience  shows  that  the  milder  cases  will  get  along 
with  much  less  change  in  diet.  For  example,  it  will  suffice  in  very 
many  cases  to  give  Penzoldt's  advice  as  to  the  glass  of  cold  water  in 
the  morning,  especially  if  a  little  common  salt  is  added ;  in  other 
cases  the  taking  of  fresh  or  cooked  fruit  on  an  empty  stomach  or 
in  ihe  evening  is  sufficient ;  or  the  morning  cigar  may  set  up  intes- 
tinal peristalsis.  ISTor  do  these  exhaust  the  possibilities.  We  can 
occasionally  utilize  these  facts  in  treatment,  at  the  same  time  that 
they  throw  light  upon  the  wide  individual  variations  in  the  irrita- 
bility of  the  intestines  in  different  subjects,  and  on  the  necessity  of 
taking  this  factor  into  account  in  each  individual  case. 

3.  Mechanical  Treatment. — The  most  important  of  such  meas- 


HABITUAL  CONSTIPATION  249 

ures  is  massage ;  it  has  already  been  discussed  in  the  General  Sec- 
tion (pages  170-1 Y2).  To  this  may  be  added,  in  many  cases,  other 
mechanical  therapeutic  agents. 

The  simplest  of  these  are  exercise,  and  various  systems  of  gym- 
nastics. 

The  value  of  the  former  should  not  be  underestimated,  although 
experience  teaches  us  not  to  expect  too  much  from  it.  We  often 
enough  meet  with  chronic  constipation  in  people  such  as  farmers 
and  officers  who  take  active  exercise.  The  fact  that  surprisingly 
good  results  are  obtained  in  the  treatment  of  constipation  in  spite 
of  absolute  rest  in  bed,  shows  that  the  importance  of  exercise  has 
heretofore  been  very  much  overestimated.  For  these  reasons  I 
have  been  led  to  prescribe  rest  in  bed,  with  suitable  diet,  in  some 
cases  of  severe  constipation  ;  and  I  particularly  remember  the  case 
of  a  lady  who  was  suifering  from  a  severe  type  of  constipation — 
whose  medical  adviser,  in  his  perplexity,  finally  felt  compelled  to 
order  her  to  take  a  bottle  of  bitter  water  every  hour — who  was  com- 
pletely and  permanently  cured  by  four  weeks  of  absolute  rest  in  bed, 
with  no  other  treatment  than  an  appropriate  diet. 

Much  more  valuable  than  simple  exercise  are  the  various  forms 
of  indoor  gymnastics,  calisthenics,  rowing,  bicycling,  riding,  tennis, 
bowling,  football,  and  the  Swedish  movements,  when  they  are 
carried  out  more  or  less  methodically.  But  they  are  not  all  equally 
useful.  For  example,  my  experience  shows  that  bicycling  does 
not  exercise  any  especial  influence  over  intestinal  activity  ;  indeed, 
one  of  my  most  obstinate  cases  was  in  the  person  of  one  v^ho  was 
moderately  addicted  to  this  sport.  The  same  is  also  true  of  riding. 
Rowing  seems  to  be  more  useful,  but,  unfortunately,  it  is  not  always 
available.  For  the  same  purpose,  the  so-called  rowing  machines 
have  been  extensively  recommended  by  some  writers. 

The  importance  of  calisthenics  and  systematic  indoor  gymnas- 
tics, as  explained  in  numerous  books  on  this  subject  (Schreber, 
Fromm,  and  others),  should  not  be  underestimated.  One  of  the 
most  useful  movements  for  strengthening  weak  abdominal  muscles 
consists  in  raising  the  trunk  slowly  from  a  horizontal  to  an  upright 
position  without  the  assistance  of  the  arras  or  legs,  and  then  allow- 
ing it  to  slowly  drop  back  again  ;  this  should  be  repeated  several 
times  each  day.  It  is  best  practised  in  a  progressive  fashion,  very 
gradually  increasing  the  angle  at  which  the  trunk  is  maintained  by 
the  muscular  exertion.  Ultimately  the  motion  of  rising  may  be  made 
against  a  slight  resistance,  such  as  that  of  the  hand  of  an  assistant 


250  DISEASES  OP  THE  INTESTINES 

laid  upon  the  forehead  (von  Wild).  Another  useful  exercise  is 
hi^h  kicking  of  the  knee,  so  that  the  anterior  surface  of  the  thigh 
is  brought  into  forcible  contact  with  the  abdomen. 

As  Williams  ^^,  Lauder  Brunton  ^^,  and  recently  Ewald  ",  have 
pointed  out,  the  position  of  the  body  during  the  act  of  defecation, 
belongs  in  a  certain  degree  to  this  class  of  measures.  These 
authors  emphasize  the  advantage  of  a  squatting  position,  in  which, 
as  is  evident,  the  abdominal  muscles  act  upon  the  rectum  to  best 
advantage.  Anyone  who  knows  from  experience  how  difficult  it  is 
to  have  an  evacuation  in  a  sitting  posture  with  the  legs  extended 
(bedpan  position),  will  concur  in  the  advice  of  these  authors,  but, 
unfortunately,  there  are  practical  difficulties  in  the  way  of  carrying 
it  out. 

4.  Concerning  the  use  of  electricity,  its  indications  and  advan- 
tages, see  the  discussion  on  pages  172-175. 

5.  With  the  thermic  measures  may  be  classed  the  various  forms 
of  hydrotherapy,  which  have  been  described  on  page  158.  Their 
eifect  depends  chiefly  upon  an  improvement  in  the  general  condition, 
by  which,  as  we  have  seen,  nutrition  and  intestinal  activity  are 
increased.  Local  or  intestinal  hydrotherajjy  is  also  of  importance 
in  the  form  of  douches  and  enemata  (page  177),  the  latter  contain- 
ing substances  which  soften  faeces  (oil,  soap,  glycerin,  etc.).  It  is 
also  known  that  the  sudden  local  application  of  cold  will  increase 
intestinal  peristalsis,  and  this  fact  may  be  taken  advantage  of  in 
therapeutics.  The  most  simple  and  at  the  same  time  a  very  effi- 
cient method,  according  to  my  experience,  consists  in  the  use  of  cold 
water  compresses  (of  course  without  an  impervious  covering).  A 
more  powerful  application  is  the  use  of  cold,  or  alternate  cold  and 
hot  jets  or  sprays  over  the  abdomen  (Scottish  douche).  The  ether 
spray  is  another  and  very  simple  method,  which  I  have  used  in 
obstinate  cases  for  a  number  of  years.  Once  or  twice  a  day,  for 
about  five  minutes,  100  cubic  centimetres  of  sulphuric  ether  are 
sprayed  upon  the  abdomen  with  the  Richardson  apparatus.  The 
chilling  so  produced  markedly  stimulates  the  muscles  of  the  abdom- 
inal wall,  and  presumably  also  the  intestine,  for  it  soon  gives  rise  to 
an  urgent  desire  to  go  to  stool.  I  will  merely  select  two  of  my  case 
histories  in  which  the  ether  spray  gave  brilHant  results: 

Case  I.  Ohstinate  constipation,  not  cured  by  diet  alone.  Complete  cure  by 
ether  spray. 

B.,  resident  of  Berlin,  fifty-four  years  old,  has  suffered  for  many  years  from 
severe  pyrosis  and  constipation.     Was  operated  on  for  hernia  in  1896,  but  with 


HABITUAL  CONSTIPATION  251 

little  improvement  in  the  constipation.  Movements  from  the  bowels  occur 
only  after  laxatives  or  enemata.  The  urine  contains  a  good  deal  of  uric  acid, 
but  there  are  no  other  signs  of  gout.  Examination  of  the  gastric  contents 
shows  a  high  degree  of  hyperacidity  with  atony.  Rectum  empty.  Irrigation 
does  not  show  the  presence  of  mucus.  Constipation  diet  was  first  tried.  A 
passage  resulted  each  day,  but  only  with  great  difficulty,  and  the  amount  was 
insufficient.  In  May,  1897,  the  ether  douche  was  used  twice  daily  for  about 
five  minutes.  The  evacuations  were  from  this  time  on  softer  and  more  free. 
After  a  fortnight's  use  of  the  spray  the  stools  were  normal.  Subsequently  the 
patient  used  it  from  time  to  time  when  there  was  delayed  evacuation.  Since 
the  year  1898  the  bowels  have  been  perfectly  regular  on  simple  constipation 
diet.  He  has  gained  6  kilos  in  weight  since  the  beginning  of  the  treatment. 
The  hyperacidity  has  been  improved  by  the  continuous  use  of  citrate  of  soda. 

Case  II.  Chronic  constipation  of  three  and  a  half  years'  standing.  Great 
abuse  of  drastics.  Results  from  diet  unsatisfactory.  Regular  action  of  the  towels 
results  immediately  from  the  use  of  the  ether  spi-ay. 

MissL.,  of  Frankfurt-am-Main,  twenty-three  years  old.  The  patient  has 
suffered  for  the  past  three  and  a  half  years  from  severe  atonic  constipation, 
with  resultant  anaemia  and  anorexia.  Purgatives  of  the  drastic  order,  which 
the  patient  has  used  for  a  long  time,  always  cause  severe  pain.  At  one 
period  membranous  enteritis  developed,  but  disappeared  later.  At  first  the 
treatment  in  my  private  clinic  consisted  in  constipation  diet,  but  the  bowels 
would  not  move  spontaneously.  Evacuations  only  followed  the  use  of  enemata 
of  soapsuds,  glycerin,  or  oil.  Fourteen  days  after  admission  the  use  of  the 
ether  spray  was  begun,  for  five  minutes  once  daily.  The  bowels  moved  daily 
thereafter,  and  after  ten  days  of  this  treatment  the  spray  was  left  off.  The 
patient  gained  15  pounds  in  weight,  and  left  after  four  weeks,  the  bowels  being 
perfectly  regular. 

Such  favourable  results  are  not  obtained  in  all  cases,  but,  be- 
cause of  its  simplicity  in  obstinate  cases,  the  ether  spray  should  be 
considered  almost  as  important  as  the  diet. 

6.  Medicinal  Treatment. — In  recent  times  there  is  a  good  deal 
of  diversity  of  opinion  among  authors  as  to  the  benefit  or  the  harm 
that  may  result  from  medicinal  treatment — that  is,  from  the  use  of 
laxatives.  Even  if  we  ignore  the  exaggerations  of  "  the  doctor  who 
follows  ISTature,"  and  whose  stock  in  trade  it  is  to  denounce  all  drugs 
as  poisonous  and  harmful,  there  still  remains  between  leading  clini- 
cians and  physicians  a  gulf  difficult  to  bridge  over. 

As  representing  one  set  of  opinions  I  may  quote  Dnnin  ^,  who 
"  most  positively  forbids  the  use  of  any  sort  of  laxative  whatever," 
and  of  the  other,  the  elder  clinician  v.  Liebermeister  ^^  who  gives 
the  advice  that  when  regular  stools  can  not  be  obtained  without  too 
much  trouble  by  dietetic  regulation,  "  suitable  laxatives  are  to  be 
used  with  regularity  each  day."     Of  the  standard  authors,  Pen- 


252  DISEASES  OF  THE  INTESTINES 

zoldt  ^"j  Nothnagel  \  Fleischer  ^^,  Rosenheim  ^^,  Ewald  ^"^  and  others' 
take  a  middle  position.  We  can  especially  recommend  Penzoldt's 
thorough  and  clear  presentation  of  the  facts  of  the  controversy. 

In  what  follows  I  shall  give  the  results  of  mj  own  experience  in 
this  matter.  I  must  concur  in  the  opinion  of  other  investigators 
who  deny  that  laxatives  always,  or  in  a  majority  of  cases,  have  a 
harmful  action.  I  know  numerous  healthy  people  who  have  taken 
a  daily  laxative  for  ten  years — particularly  rhubarb — without  any 
injury  to  the  intestine  or  to  their  general  health.  These  people 
would  with  justice  indignantly  refuse  to  exchange  their  efficient  and 
simple  pill  for  monotonous  and  burdensome  dietetic  regulations. 
From  this  sort  of  case — one  which  seldom  comes  under  professional 
notice — are  to  be  distinguished  two  other  varieties :  the  first,  in 
which  laxatives  do  have  an  eifect,  but  occasion  gastric  *  or  intestinal 
discomfort,  loss  of  appetite,  emaciation,  etc.,  and  second,  those  in 
which  laxatives  have  either  no  action  or  only  an  inadequate  one. 
In  both  cases  it  is  not  a  question  of  the  further  use  of  laxatives,  for 
by  the  time  that  the  patients  seek  professional  advice  the  milder 
agents  have  ceased  to  act,  and  they  have  found  that  the  more  pow- 
erful ones  sooner  or  later  become  inert  against  the  intestinal  tor- 
pidity, or  augment  the  other  discomforts  just  mentioned. 

It  is  in  these  very  cases  that  a  rational  diet,  possibly  in  con- 
junction with  some  of  the  above-described  methods,  achieves  its 
greatest  triumph  ;  and,  even  when  it  is  not  fully  successful — as  some- 
times happens  in  very  protracted  cases — a  satisfactory  result  may 
be  obtained  with  the  assistance  of  small,  perhaps  minimal  doses  of 
some  mild  laxative,  or,  still  better,  by  enemata  of  some  suitable  fluid 
(oil,  etc.). 

Thus  the  question  as  to  the  indications  for  the  use  of  laxative 
drugs  is  virtually  self-answered.  [Aside  from  the  above-mentioned 
cases  in  which  their  long- continued  use  has  produced  no  injurious 
effects],  we  employ  this  class  of  drugs  only  when  a  constipation  diet, 
patiently  persevered  in,  and  if  necessary  assisted  by  other  methods, 
is  found  inefficient. 

We  have  already  expressed  our  views  concerning  the  choice  of 
laxatives  in  the  General  Section  (page  186  et  seq.),  and  have  pointed 
out  that  each  of  them  has  its  special  use  and  indications.  These 
are  essentially  dependent  upon  the  state  of  the  stomach  and,  in  cer- 

*  Wiczkowski  has  recently  made  the  interesting  observation  (Archiv  f.  Ver- 
dauungskrankheiten, Bd.  iv,  S.  407)  that  laxatives  materially  diminish,  while 
opiates  increase,  the  acid  secretion  of  the  stomach. 


HABITUAL  CONSTIPATION  253 

tain  cases,  of  the  liver.  For  instance,  calcined  magnesia  and 
Carlsbad  salts  are  also  very  excellent  antacid  remedies,  and  podo- 
phyllin  and  euonjmin  equally  good  cholagogues.  In  appropriate 
cases  advantage  must  be  taken  of  such  facts. 

Laxatives  may  often  be  administered  by  the  rectum  in  the  form 
of  small  enemata  or  as  suppositories.  The  most  popular  and  effi- 
cient, especially  in  the  milder  cases,  is  glycerin  in  doses  of  1  to  8 
grams.  It  is  evident  that  their  effect  does  not  extend  beyond  the 
lowermost  segments  of  the  colon.  Hiller^*^  and,  more  recently, 
Kohlstock  ^^  have  recommended  the  use  of  the  active  principles 
of  approved  laxatives  per  rectum.  According  to  Kohlstock,  the 
most  serviceable  are  aloin,  cathartic  acid,  and,  for  especially  obstinate 
cases,  colocynthin  and  citrullin.     The  following  are  the  formulae  : 

^  Aloin 1.0 

Formamid 10.0 

(A  suitable  dose  is  0.4  to  0.5  of  aloin.) 

1^   Colocynthin 1.0 

Spirit., 

Glycerin ää     12.0 

(A  suitable  dose  of  colocynthin  is  0.01  to  0.04.) 

^  Acid,  cathartinic.  e  senna 3.0 

Aq.  destillat 7.0 

Sod.  bicarb,  q.  s.  ad  react,  alkalin. 
(A  suitable  dose  of  cathartic  acid  is  0.6.) 

^   Citrullini 2.0 

Spirit., 

Glyceringe ää     49.0 

(A  suitable  dose  of  citrullin  is  0.02.) 

Kohlstock  states  that  these  concentrated  enemata  are  prompt 
and  painless  in  their  action.  The  only  obstacle  to  their  more  gen- 
eral use  is  their  high  cost.* 

Up  to  the  present  time  the  subcutaneous  use  of  purgatives 
(aloin,  colocynthin,  citrullin,  etc.)  has  not  been  very  successful. 
Reference  should  be  made  at  this  point  to  the  subcutaneous  use  of 
magnesium  sulphate  in  doses  of  0.12  to  0.18,  as  recommended  by 
Wood^^  and  by  Eakins^^.  Wood  states  that  he  has  obtained  results 
in  YO  per  cent  of  cases  of  constipation ;  and  Eakins,  that  even  in  a 
case  of  faecal  obstruction  he  obtained  copious  evacuations  and  cessa- 

*  The  preparations  mentioned  are  manufactured  by  Merck  (Darmstadt). 


254  DISEASES   OP   THE  INTESTINES 

tion  of  the  threatening  symptoms  after  ten  hours.  Scarbinato  ^  also 
had  positive  results,  although,  as  he  mentions,  the  effect  of  subcuta- 
neous treatment  is  neither  marked  nor  constant. 

My  own  investigations  with  doses  as  large  as  0.5  of  magnesium 
sulphate  were  not  productive  of  any  distinctly  noticeable  laxative 
effect. 

In  the  same  communication  Scarbinato  describes  another  pro- 
cedure which  is  scarcely  known,  at  least  in  Germany  :  the  endermic 
treatment  of  constipation  by  croton  oil  (6  to  10  drops  in  15  to  20 
gm.  ol.  olivae).  In  four  patients  with  chronic  constipation,  this 
procedure  produced  regular  fluid  movements,  often  accompanied 
by  abdominal  pain.  Oleum  ricini,  used  in  the  same  way,  gave 
negative  results. 

Those  substances  which  set  up  peristalsis  by  mechanical  irrita- 
tion occupy  a  mid-position  between  medicinal  and  dietetic  agents. 
Among  these  are  the  preparations  of  linseed,  of  which  a  table- 
spoonful  is  allowed  to  soak  in  water  and  taken  as  a  drink  on  an 
empty  stomach.  A  particularly  agreeable  and,  as  I  know,  an  effi- 
cient variety  is  the  linseed  of  Tarin,  which  is  distinguished  by  its 
large  size  and  elegant  shape.  The  large  amount  of  oil  contained 
in  these  preparations  seems  to  account  for  part  of  the  effect.  It 
appears  to  me  very  possible  for  some  of  the  seed  husks  to  gain  access 
to  the  vermiform  appendix  and  thus  give  rise  to  inflammation.  This 
may  be  a  purely  theoretical  idea,  but  it  has  nevertheless  deterred 
me  from  a  very  extensive  use  of  this  simple  and  efficient  remedy. 

7.  The  Tiydi' other apeutic  treatment  of  chronic  constipation  has 
been  discussed  in  the  General  Section  (page  158). 

Among  the  complications  of  chronic  constipation,  the  treatment 
of  flatulent  colic  deserves  a  brief  discussion. 

As  we  are  here  dealing  with  a  spastic  condition  of  the  intestinal 
canal,  the  preference  should  be  given  to  opium  in  small  doses  (ext. 
opii,  0.01  to  0.02).  Such  doses  will  not  only  allay  the  pain  but  will 
promote  an  evacuation.  The  use  of  laxatives,  or,  better  still,  of  a 
suitable  enema,  is  indicated  only  after  the  painful  contractions  have 
subsided. 


DISPLACEMENTS   OF   THE   INTESTINES  255 

B.    DISPLACEMENTS    OF    THE    INTESTINES 

Symptomatology  and  Diagnosis 

A  short  review  of  the  most  important  anomalies  of  position  of 
the  intestines  has  been  given  in  the  General  Section  (page  20 
et  seq.),  and  to  this  we  refer  the  reader.  In  what  follows,  an 
attempt  will  be  made  to  discuss  briefly  the  clinical  manifestations 
and  the  resultant  therapeutic  indications.  For  practical  purposes, 
dislocations  of  the  large  intestine  need  be  alone  considered.  Those 
of  the  small  intestine  produce  appreciable  symptoms  only  when 
there  is  a  marked  interference  with  peristalsis,  such  as  may  arise 
from  acute  kinkings,  as  caused  by  tumours,  adhesions,  compressions, 
etc.  We  shall  return  to  this  subject  in  the  chapter  on  Stenoses  of 
the  Intestine.  Malpositions  of  the  large  intestine  may  either  exist 
for  a  long  time  without  causing  any  disturbance  of  well-being,  or 
may  occasion  manifold  symptoms,  or,  finally,  may  disguise  the  clin- 
ical picture  to  such  a  degree  that  only  a  lucky  chance,  or  an  autopsy 
in  vivo,  or  sometimes  only  a  post-mortem  examination,  will  show 
the  true  condition  of  affairs. 

The  functional  disturbances  which,  as  has  been  said,  are  some- 
times present  were  not  unknown  to  the  older  physicians — Mor- 
gagni, De  Häen,  Esquirol,  and  Ruysch.  Yirchow^^,  in  his  famous 
treatise  on  the  Diseases  of  the  Abdomen,  from  an  Historical,  Crit- 
ical, and  Scientific  Standpoint,  has  long  ago  and  in  a  classical  man- 
ner described  the  importance  of  peritoneal  fixation  as  affecting  the 
onward  progress  of  faeces.  The  pathological  importance  of  dis- 
placements was  at  times  quite  forgotten  or  underestimated,  and 
at  times  unduly  exaggerated  (Esquirol,  Yötsch),  until  recently  the 
subject  has  been  given  a  new  prominence  by  Landau's  fruitful 
researches  on  the  subject  of  floating  kidney  and  pendulous  abdomen, 
and  Glenard's  original  though  somewhat  fantastic  doctrine  of  en- 
teroptosis.  The  valuable  contributions  of  Leichtenstern  ^^,  Cursch- 
mann  ~',  and  Fleiner  ^  have  notably  enriched  our  knowledge  con- 
cerning the  origin  and  clinical  significance  of  displacements  of  the 
intestines. 

According  to  Fleiner,  displacements  of  the  colon  may  owe  their 
origin  to  abnormal  curves  and  angular  flexures  which  interfere  with 
the  fjBcal  movements.  These  are  favored  by  increased  pressure 
upon  certain  segments  of  the  large  intestine  by  ill-fitting  corsets, 
belts,  or,  in  the  case  of  men,  by  an  habitual  stooping  carriage  and 


256  DISEASES   OP   THE  INTESTINES 

sedentary  mode  of  life.  In  this  way  dilatation  of  the  affected  seg- 
ments occurs,  f£eces  and  gas  accumulate,  and  the  clinical  picture  of 
atonic  constipation  is  developed. 

Soon  organic  changes  in  the  wall  of  the  intestine  occur.  Catarrh 
develops,  and  there  is  then  added  diarrhoea,  or  diarrhoea  alternat- 
ing with  constipation,  or  constipation  with  membranous  enteritis. 
Neuralgic  colicky  pains  set  in,  which,  according  to  Fleiner,  are 
easily  mistaken  for  intercostal  neuralgia,  biliary  colic,  renal  colic, 
spinal  crises — even  for  duodenal  ulcer.  Fleiner  has  given  the 
details  of  several  very  instructive  clinical  histories  which  show  how 
difficult  it  is  to  avoid  mistakes,  especially  in  confounding  these 
paroxysmal  pains  with  biliary  colic.  I  can  add  from  my  personal 
experience  that  it  frequently  happens,  especially  in  women,  that  the 
symptoms  of  gastrointestinal  neurasthenia  are  present.  There  are 
anorexia,  oppression  in  the  epigastrium,  intestinal  colic,  flatulence, 
constipation,  mental  depression,  disinclination  for  work,  loss  of 
weight,  etc.  Objective  signs  are  ptosis  of  the  stomach  and  colon, 
displacement  of  the  kidneys,  liver,  or  spleen,  and  sometimes  of  the 
uterus. 

Many  physicians  are  puzzled  when  they  come  to  deal  with  this 
condition.  Some  think  of  anaemia  and  prescribe  iron ;  others  sus- 
pect gastric  or  intestinal  catarrh  and  prescribe  bismuth  or  laxatives ; 
others  diagnosticate  hysteria  and  attempt  to  cure  with  valerian, 
bromids,  or  asafoetida. 

Displacements  of  the  intestine  may,  however,  cause  very  dan- 
gerous changes  in  the  intestines,  and  may  endanger  life.  Thus 
Curschmann  has  described  two  cases  of  upward  flexure  of  the 
caecum  with  absolute  occlusion  of  the  intestine  from  the  acute 
bending.  Both  patients  died  with  symptoms  of  acute  obstruction. 
When  there  are  abnormal  bends  of  the  transverse  colon  and  its 
flexures,  there  may  be  an  acute  angle  formed  which  causes  partial 
or  total  obstruction. 

These  changes  of  position  are  of  clinical  importance  also,  be- 
cause they  may  lead  to  errors  in  diagnosis  not  liable  to  arise  in  any 
other  way.  Curschmann  has  reported  very  interesting  cases  in 
which  the  caecum  was  bent  so  as  to  bring  the  vermiform  process 
directly  into  contact  with  the  liver  (see  Fig.  24).  If  the  appendix 
became  inflamed  in  this  situation  the  exudate  would  be  close  to  the 
right  costal  arch. 

In  case  of  congenital  shortness  or  absence  of  the  ascending  por- 
tion of  the  colon,  the  c^cum  with  its  appendix  might  be  close  to  or 


DISPLACEMENTS  OF   THE   INTESTINES 


257 


behind  the  liver.  In  a  case  described  by  Curschmann  (see  Fig.  25), 
a  perforating  perityphhtis  was  present  while  the  clinical  signs  were 
those  of  cholelithiasis. 

Dislocations  of  the  colon  are  especially  liable  to  be  confounded 
with  diseases  of  the  liver,     von  Leube'^^  and  subsequently  Fleiner=« 


Fig.  24* — Vermiform  Appendix  in  Con- 
tact WITH  THE  Under  Surface  of 
THE  Liver.     (Curschmann.) 


Fig.  25.— Vermiform  Appendix   lying   be- 
hind  THE   Right  Lobe    of   the   Liver. 

(Curschmann.) 


and  Curschmann  2^  have  called  attention  to  the  fact  that  abnormal 
elevation  and  gaseous  distention  of  the  transverse  colon  may  reduce 
or  abohsh  the  area  of  liver  dulness. 

I  have  often  observed  the  absence  of  liver  dulness  in  males. 
As  Curschmann  observes,  this  may  often  cause  difficulties  in  map- 
ping out  the  edge  of  the  liver  in  hepatic  cirrhosis.  The  normal 
position  of  the  liver  dulness  in  the  anterior  and  posterior  axillary 
lines  enables  a  decision  to  be  reached.  In  one  of  the  cases  which 
Curschmann  has  described  and  illustrated,  a  duodenal  ulcer  was 
mistaken  for  a  subphrenic  abscess  because  the  flexures  of  the  colon 
were  absent,  both  limbs  running  almost  parallel.  According  to 
Curschmann,  when  the  flexures  are  exaggerated  into  loops  the 
splenic  dulness  may  be  obscured. 

It  is  well  known  that  loops  with  coincident  elongation  are  found 


*  Thanks  are  due  to  Professor  Curschmann,  of  Leipzig,  for  permission  to  re- 
produce Figs.  24-28. 


258 


DISEASES   OP   THE   INTESTINES 


with  especial  frequency  in  the  transverse  colon  and  at  the  flexures. 
They  are  chiefly  single ;  next  in  frequency  come  the  M  or  V 
shapes,  and  rarely  the  double  looping  seen  in  Fig.  26.  If  the 
flexures  become  still  further  enlarged,  they  may  dip  down  as  far  as 


Fig.  26. — Double  Looping    of   the    Trans- 
verse Colon.     (Cursohmann.) 


Fig.  27. — Double    Looping  of  the  Sig- 
moid Flexure.     (Curschmann.) 


the  brim  of  the  pelvis.  It  has  long  been  known  that  abnormal 
loops  of  the  sigmoid  flexure  may  give  rise  to  serious  mistakes. 
We  have  already  mentioned  (page  23)  that  when  the  sigmoid  flexure 
is  strongly  inflated,  it  almost  always  encroaches  upon  the  right  lower 
quadrant  of  the  abdomen,  and  therefore  lies  close  to  the  caecum. 
When  there  is  a  suspicion  of  volvulus  in  that  region,  the  physical 
signs  of  distention  of  the  sigmoid  flexure  should  be  looked  for. 
The  importance  of  abnormal  loops  of  the  sigmoid  flexure  when 
operative  procedures  are  in  question,  when  an  artificial  anus  is  to  be 
constructed,  or  when  a  loop  is  to  be  exsected,  is  of  course  evident. 
The  difficulties  may  be  very  much  increased  when  an  abnormally 
long  sigmoid  flexure  is  arranged  in  a  double  (Fig.  27)  or  in  multiple 
loops  (Fig.  28). 

The  latter  condition  may  be  considered  on  the  border  line  be- 
tween normal  and  pathological ;  it  presents  favourable  conditions 
for  the  formation  of  a  volvulus. 

The  diagnosis  of  certain  forms  of  intestinal  dislocation,  such  as 


DISPLACEMENTS  OF  THE  INTESTINES 


259 


Fig.    28. — Multiple    Looping    of    the 
Sigmoid  Flexure.     (Curschmann.) 


the  common  depression  or  elevation  of  the  transverse  colon,  offers 
no  special  difficulty.  In  most  instances  gross  variations  of  this  kind 
can  be  determined  with  probabili- 
ty or  certainty  by  inflation  of  the 
intestines  with  air,  by  methodical 
distention  with  water,  or  by  care- 
ful percussion.  The  case  is  quite 
different  with  displacements  of  the 
csecum,  deformities  and  disloca- 
tions of  the  sigmoid  flexure,  ab- 
sence of  the  flexures,  abnormal 
looping,  and  other  irregular  con- 
ditions. The  possibility  of  an 
anomaly  of  position  must  be  taken 
into  consideration  in  making  a  di- 
agnosis. Curschmann  was  fortu- 
nate enough  to  do  this  in  one  in- 
stance. Perhaps  the  capsule  meth- 
od, with  the  assistance  of  the  Rönt- 
gen rays,  as  recently  described  by 
Levy-Dorn  and  myself  ^'^,  will  have  some  value  for  the  recognition 
of  these  anomalies  of  position  or  form.  Practical  experience  is, 
however,  still  lacking.  When  the  clinical  signs  are  obscure,  the 
possibility  of  such  variations  must  be  taken  into  consideration. 

Tkeatment 

The  description  of  the  treatment  of  changes  in  position  or  form 
of  the  bowel  touches  upon  many  chapters  of  intestinal  pathology ; 
it  is  not  possible,  therefore,  to  enter  into  details  in  this  place.* 
Prolapse  of  the  transverse  colon,  however,  which  is  usually  only  a 
part  of  a  general  visceral  ptosis,  requires  a  few  brief  remarks.  The 
fundamental  therapeutic  maxims  agree  essentially  with  those  in  gas- 
troptosis  (see  Diseases  of  the  Stomach,  Part  II,  page  183).  They 
consist  primarily  in  complete  rest  in  a  horizontal  position  and  in  a 
strengthenina;  diet.  The  latter  should  not  be  a  routine  one,  such 
as  Weir-Mitchell's,  but  should  be  adapted  to  the  necessities  of  each 
case,  with  reference  to  the  functional  disturbances  of  the  alimentary 
canal. 

Constipation  or  colitis  must  be  treated  in  the  manner  advised  in 
the  chapters  on  these  affections.  By  the  use  of  massage,  hydro- 
therapy, and  electrotherapy,  the  effects  of  the  dietetic  prescriptions 


260  DISEASES  OF  THE  INTESTINES 

may  be  enhanced  and  the  general  condition  improved.  A  suitable 
abdominal  supporter  is  useful  in  assisting  the  weak  abdominal 
muscles. 

Treatment  in  a  sanitarium  is  far  preferable  to  home  or  ambu- 
latory treatment. 

LITERATURE 

1.  Nothnagel.     Darmkrankheiten,  S.  27. 

2.  Emminghaus.     Münchener  med.  Wochenschr.,  1894,  No.  5  u.  6. 

3.  Dunin.     üeber  habituelle  Stuhlverstopfung,  deren  Ursachen  u.   Behand- 

lung, Berliner  Klinik,  1891. 

4.  Glenard.     De  TEnteroptose,  1889. 

5.  Fleiner.     Berliner  klin.  Wochenschr.,  1893,  No.  3. 

■   6.  G.  Kobler.     Wiener  klin.  Wochenschr.,  1898,  No.  20. 

7.  Voötsch.     Koprostase,  1874. 

8.  Bouchard.     Legons  sur  les  Autointoxications,  Paris,  1887. 

9.  Feyat.     De  la  Constipation  et  des  Phenomenes  qu'elle  provoque,  1890. 

10.  Penzoldt.     Klinische  Arzneimittellehre,  3te  Aufl  ,  S.  20  u.  f. 

11.  von  Wild.     Sammlung  zwangloser  Abhandlungen  a.  d.  Gebiete  der  Frau- 

enheilkunde u.  Gebui-tshülfe,  1897,  Bd.  ii,  Heft  3. 

12.  Penzoldt.     In  Penzoldt-Stintzing,   Handbuch   d.    spec.    Therapie   innerer 

Krankheiten,  Bd.  iv,  S.  514. 

13.  Rosenheim.     Pathologie   u.  Therapie   der   Krankheiten  d.  Darmes,   1893, 

S.  511. 

14.  Wegele.     Diätetische  Behandlung  d.  Magendarmerkrankungen,   1896,  S. 

107. 

15.  Williams.     Boston  Medical  Journal,  Aug.  23,  1888. 

16.  Lauder  Brunton.     Wiener  med.  Blätter,  1896,  Nos.  37-39. 

17.  C.  A.  Ewald.     Berliner  Klinik,  1897,  S.  16. 

18.  von  Liebermeister.     Vorlesungen   über   specielle   Pathologie   u.  Therapie, 

Bd.  V,  ö.  168. 

19.  Fleischer.     Lehrbuch  d.  inneren  Medicin. 

20.  Hiller.     Zeitschr.  f.  klin.  Medicin,  1882,  Bd.  iv,  S.  481. 

21.  Kohlstock.     Charite-Annalen,  1893,  Bd.  xvii. 

22.  Wood.     The  Therapeutical  Gazette.  Jan.  15,  1895.     (Cited  from  Arch.  f. 

Verdauungskrankheiten,  Bd.  i,  S.  320.) 

23.  Eakins.      The  Australian  Med.    Gaz.,   Jan.   15,   1895.     (Cited  from  same 

source  as  22.) 

24.  Scarpinato.     Arch,    fermacolog.   e  therap.,  March  1,   1896.      (Cited  from 

Arch.  f.  Verdauungskr.,  Bd.  ii,  S.  396.) 

25.  Virchow.     Virchow's  Archiv,  1853,  Bd.  v,  S.  281. 

26.  Leichtenstern.      von  Ziemssen's  Handbuch,   Bd.  vii.   Heft   2,    Aufi.  2,    S. 

509  u.  f . 

27.  Curschmann.     Deutsches  Arch.  f.  klin.  Medicin,  1894,  Bd.  liii,  S.  1. 

28.  Fleiner.     Münchener  med.  Wochenschr.,  1895,  Nos.  42-45. 

29.  von  Leube.     von  Ziemssen's  Handbuch,  Bd.  viii,  H.  2,  Aufl.  2,  S.  242. 

30.  Boas  u.  Levy-Dorn.     Deutsch,  med.  Wochenschr.,  1898,  No.  2. 


CHAPTER  XY 

ULCERS   OF  THE  INTESTINES 

Introductory  Remarhs. — An  extraordinary  variety  of  ulcers 
occur  in  the  intestinal  canal.  It  is  unnecessary  to  describe  tlieni 
all  in  this  chapter,  as  many  are  only  complications  or  localizations 
of  diseases  which  do  not  fall  within  the  province  of  this  work. 
Such,  for  example,  are  the  ulcerations  accompanying  acute  infec- 
tious diseases  (typhoid  fever,  acute  dysentery,  diphtheria,  anthrax, 
sepsis,  erysipelas,  variola,  puerperal  fever,  leprosy),  as  well  as  con- 
stitutional diseases  (gout,  scurvy,  leucsemia).  The  toxic  ulcerations 
from  mercury,  arsenic,  antimony,  as  well  as  the  so-called  uremic 
ulcers,  bear  such  slight  relations  to  intestinal  pathology  that  there 
is  no  necessity  for  describing  them  here.  There  remain  only  those 
forms  of  ulceration  which,  from  their  clinical  symptoms,  pursue  an 
independent  course.  These  are,  naming  them  in  the  order  of  their 
frequency:  the  catarrhal  idcer,  the  follicular  ulcer,  the  stercoral 
ulcer,  the  tuberculous  tdcer,  the  chronic  dysenteric  ulcer,  the  syphi- 
litic ulcer,  the  amyloid  ulcer,  and  finally  the  emholic  and  thrombotic 
ulcer.  The  duodenal  ulcer,  a  peculiar  clinical  type,  will  be  de- 
scribed separately,  and  in  that  connection  a  few  remarks  will  be 
made  on  ulcers  due  to  burns. 

Catarrhal  and  folUctdar  ulcers  are  tolerably  often  observed  in 
intestinal  catarrhs. "^  Their  favorite  location  is  the  large  intestine, 
and  it  is  only  exceptionally  that  they  are  found  higher  up.  They 
owe  their  origin  to  slight  losses  of  epithelium,  which  permit  of  the 
entrance  of  organisms  which  excite  inflammation,  or  of  substances 
which  are  chemical  irritants.  The  superficial  strata  of  the  mucous 
membrane  break  down  and  a  superficial  erosion  develops  ;  if  the 
process  goes  on,  an  ulcer  of  more  or  less  depth  may  be  formed 
which  may  penetrate  to  the  serous  coat,  and  terminate  in  perfora- 
tion. Several  small  ulcers  may  become  confluent  and  give  rise  to  a 
single  large  one.  If  the  ulcer  heals,  subsequent  cicatricial  contrac- 
tion may  lead  to  intestinal  stenosis. 


18 


261 


262  DISEASES  OF   THE  INTESTINES 

Tlie  follicular  ulcers  originate  primarily  from  an  inflammation 
of  a  folKcle  (suppurative  follicular  enteritis),  in  wliicli  the  swelling- 
gradually  increases,  su]3puration  and  rupture  occur,  with  resulting- 
loss  of  substance — the  follicular  ulcer.  Sometimes  these  points  are 
so  numerous  that  the  mucous  membrane  presents  a  sievelike  appear- 
ance. From  undermining  of  the  mucous  membrane,  these  ulcers,  as 
in  the  variety  just  mentioned,  may  coalesce  to  form  larger  ones  of 
sinuous  form. 

The  stercoral  ulcer,  or  the  decubital  ulcer  of  Grawitz,  is  found 
almost  exclusively  in  the  large  intestine,  and  especially  at  those 
points  at  which  the  pressure  of  the  faeces  is  most  marked — at  the 
flexures  of  the  colon,  in  the  caecum,  the  sigmoid  flexure,  the  rec- 
tum, and  very  frequently  in  the  vei-miform  appendix.  In  the  latter 
situation  it  may,  under  certain  circumstances,  give  rise  to  perityph- 
litis. Stercoral  ulcers  are  frequently  seen  to  develop  above  ste- 
nosed  portions  of  the  intestine.  They  may  be  superficial  or  deep, 
and  lead  to  extensive  loss  of  substance  with  suppuration.  If  they 
heal,  stenosis  may  follow  from  cicatricial  contraction,  but  extensive 
strictures  secondary  to  stercoral  ulcers  are  of  great  rarity. 

The  tuherculous  ulcer  is  by  far  the  most  important  variety,  and 
the  one  which  has  been  most  carefully  studied.  A  distinction  is. 
made  between  primary  intestinal  tuberculosis,  which  develops  in 
the  intestine  of  an  individual  who  has  heretofore  been  free  from 
tuberculosis,  and  secondary  intestinal  tuberculosis,  which  arises  in 
connection  with  some  other  tuberculous  afiection.  The  occurence 
of  primary  intestinal  tuberculosis  is  still  disputed  by  Klebs  ^  and 
von  Leube  ^ ;  but  at  the  present  day  we  must  admit  that  unim- 
peachable observations  (Behrens^,  Eisenhart*,  Wyss^,  Melchior^) 
have  demonstrated  that  it  may  rarely  occur  in  older  children  and 
adults.  In  earliest  childhood  intestinal  and  mesenteric  tuberculosis 
is  of  very  frequent  occurrence.  Investigations,  particularly  those 
of  Bollinger  and  his  pupils,  give  convincing  evidence  that  this  form 
of  tuberculosis  should  be  regarded  as  dietary  (milk  and  the  flesh  of 
tuberculous  cows). 

Secondary  intestinal  tuberculosis,  on  the  other  hand,  is  one  of 
the  most  frequent  complications  of  pulmonary  tuberculosis.  Ac- 
cording to  the  statistics  of  Eisenhart  *,  based  upon  1,000  autopsies, 
it  was  present  in  56.3  per  cent.  Other  authors,  such  as  Hamann''', 
find  the  percentage  to  be  higher ;  and  Herxheimer  ^  states  that  in 
58  cases  there  was  only  1  in  which  tuberculous  disease  of  the  intes- 
tine could  not  be  found.     The  mode  of  origin  of  intestinal  tubercu- 


ULCERS   OF   THE   INTESTINES  263 

losis,  long  ago  attributed  by  Klebs  to  the  swallowing  of  tuberculous 
sputum,  is  now  recognised  to  be  an  auto -intoxication  with  material 
containing  bacilli.  This  may  even  be  proved  in  an  indirect  way 
from  the  statistics  of  Eisenhart.  In  them  it  appears  that  out  of  the 
1,000  autopsies  on  [all  varieties  of]  tuberculous  patients,  of  whom 
567  were  cases  of  intestinal  tuberculosis,  there  were  only  3  cases 
in  which  the  intestinal  tuberculosis  was  not  associated  with  puhiio- 
nary  tuberculosis.  Infection  of  the  intestine  by  the  tubercle  bacil- 
lus naturally  results  if  erosions  are  present ;  the  researches  of  Orth^ 
are  especially  instructive  on  this  point.  But  it  is  important  to  note 
that,  according  to  the  investigations  of  Fischer  ^°,  Dobroklonsky ", 
Tschitscho wisch  ^^,  and  others,  tuberculosis  may  be  conveyed  to  the 
mucous  membrane  of  the  intestine  even  when  its  epithelium  is  intact. 
Tuberculous  lesions  are  not  distributed  uniformly  throughout 
the  intestines  ;  some  regions — the  lower  part  of  the  ileum  and  of  the 
caecum — show  a  special  liability  to  invasion.  The  very  slow  move- 
ment of  the  chyle  in  these  regions  is  the  chief  cause  why  this  is  the 
site  of  preference.  Below  the  csecum  and  above  the  ileum  the 
development  of  tuberculous  ulcers  is  much  more  infrequent.  The 
process  usually  begins  in  Beyer's  patches  and  in  the  solitary  follicles. 
Small  nodules  are  developed  in  them  (miliary  tubercles)  and  the 
lymph  follicles  become  smaller.  By  their  rupture  ulcers  are  formed. 
Fresh  eruptions  of  tubercle  spring  up  from  its  base  and  in  its 
neighbourhood.  The  original  lenticular  ulcers  increase  in  size  by 
coalescence,  and,  breaking  through  the  muscular  coat,  reach  the 
serous  covering  and  sometimes  penetrate  into  the  abdominal  cavity. 
The  ulcers  may  lie  with  their  longer  axis  parallel  to  the  course  of  the 
intestine  (longitudinal),  or  at  right  angles  to  it  (encircling).  The 
former  develop  in  a  Beyer's  patch,  the  latter  follow  the  course  of 
the  vessels  ;  yet  some  have  quite  an  irregular  outline.  Tuberculous 
ulcers  of  the  intestine  exhibit  in  the  main  but  a  very  slight  tendency 
to  heal.  Out  of  Eisenhart's  *  56Y  cases,  only  10  showed  ulcers  which 
had  completely  healed ;  in  25  cases  there  was  partial  cicatrization. 
In  consequence  of  cicatricial  contraction,  intestinal  tuberculosis 
may  produce  simple  or  multiple  stricture,  in  rare  cases  complete 
occlusion  ^^.  In  the  chapter  on  Intestinal  Stenosis  this  subject  will 
be  taken  up  more  in  detail.  Berforation  of  a  tuberculous  ulcer  is 
a  rare  occurrence  (about  5  to  10  per  cent).  It  usually  takes  place 
in  the  csecum  or  vermiform  appendix,  and  opens  into  a  space  shut 
off  by  previous  inflammatory  adhesions,  and  only  very  rarely  into 
the  general  peritoneal  cavity. 


264  DISEASES  OP  THE  INTESTINES 

A  few  remarks  on  ileo-csecal  tuberculous  tumours  may  be  intro- 
duced at  this  point,  because  they  arise  from  tuberculous  ulcerations, 
although,  strictly  speaking,  they  fall  under  the  head  of  tumours. 

Our  knowledge  of  ileo-csecal  tumours  is  of  recent  date,  and  the 
credit  for  it  is  chiefly  due  to  the  experience  gained  from  the  opera- 
tive surgery  of  the  intestines.  Following  Conrath  ^*,  Durante  (1890) 
was  the  first  to  point  out  the  features  of  resemblance  and  the  differ- 
ences between  carcinoma  and  tuberculous  tumour  of  the  caecum. 
In  1891,  he  was  followed  by  Billroth  ^^,  Henri  Hartmann  and 
Pilliet  ^^,  and  Salzer  ^'^,  who  laid  stress  upon  the  tuberculous  charac- 
ter of  the  tumours  in  question.  The  excellent  work  of  Czerny  ^^, 
König  ^^,  Körte  ^°,  Hofmeister  ^\  and  Conrath  ^^  has  so  far  advanced 
our  knowledge  of  the  pathology  and  operative  treatment  of  tuber- 
culous tumours  of  the  ileo-csecal  region  that  at  the  present  day  our 
clinical  knowledge  of  them  is  complete  in  all  essential  details. 
From  the  medical  side,  however,  they  have  received  very  little 
attention  except  in  the  paper  of  Obrastzow  which  will  be  alluded 
to  later,  so  that  I  think  a  detailed  consideration  of  the  subject  is 
indicated  in  this  place. 

The  tuberculous  tumour  (see  Fig.  29)  is  usually  the  product  of 
inflammatory  infiltration  from  multiple  tuberculous  ulcerations. 
These  partially  cicatrize,  with  the  formation  of  a  large  amount  of 
scar  tissue,  which  gradually  contracts  so  as  to  cause  a  stenosis  of  the 
lumen  of  the  intestine.  It  is  evident  that  such  stenosis  will  favour 
hypertrophy  of  the  coats  of  the  intestine.  The  contraction  is 
most  marked  in  the  vicinity  of  the  ileo-csecal  valve  because  the 
tissue  shrinkage  is  greatest  at  this  point ;  the  valve  itself  is  usually 
involved  in  the  process. 

The  ulceration  may  originate  in  the  serous  coat  and  extend 
deeply.  Conrath  attributes  this  to  a  direct  infection  from  local- 
ized tubercular  disease  of  the  lymph  glands ;  while  the  mucous- 
membrane  form  is  considei*ed  to  be  an  auto-infection  from  tuber- 
culous sputum,  or  as  a  primary  tuberculosis — a  tuberculosis  from 
ingesta  in  the  stricter  sense.  Conrath  traces  the  fact  that  caecal 
tuberculosis  usually  remains  localized,  to  several  causes.  One  is, 
that  the  tubercular  deposits  in  the  subserous  layer  do  not  contain 
so  many  bacilli  as  those  in  the  deeper  strata,  and  thus  general- 
ization is  hindered.  For  this  reason  the  pulmonary  phthisis  ob- 
served in  connection  with  caecal  tuberculosis  is  usually  of  mild 
form,  and  in  contra-distinction  to  fully  developed  phthisis,  the  oppor- 
tunity for  bacillary  infection  of  the  intestine  is  relatively  small. 


ULCERS   OF   THE   INTESTINES 


265 


Evidently  we  must  not,  even  in  this  case,  lose  sight  of  the  fact  that 
on  account  of  its  location  the  caecum  affords  a  favourable  seat  for 
the  deposit  of  tuberculous  products,  and  most  unfavourable  condi- 


FiG.  29. — Tuberculosis  of  the  Cecum.     (Wölfler — Coneath.) 
a,  junction  of  CEecura  and  ascending  colon  ;  b,  junction  of  ileum  and  cfficum. 

tions  for  their  cure.     The  conditions  are  apparently  very  analogous 
to  those  in  primary  tuberculosis  of  the  appendix,  which  once  estab- 


266  DISEASES  OF  THE  INTESTINES 

lished,  in  like  manner  and  doubtless  for  the  same  reasons,  and  in 
spite  of  any  sort  of  treatment,  leads  to  progressive  changes. 

The  chronic  dysenteric  ulcer  develops  as  a  sequel  of  the  acute 
form.  The  symptoms  may  be  those  of  an  unusual  prolongation  of 
the  disease,  or  they  may  set  in  shortly  after  apparent  cure  by  one  or 
more  relapses ;  or,  finally,  what  was  originally  a  catarrhal  diarrhoea 
may  terminate  in  dysentery.  In  its  essential  features  the  ana- 
tomical picture  of  chronic  dysentery  resembles  that  of  the  acute 
form,  and  is  characterized  by  the  formation  of  a  variable  number 
of  deep-seated  ulcers  of  the  large  intestine  with  raised  and  un- 
dermined edges.  Accompanying  this  there  are  the  symptoms  of 
an  intense  catarrh  of  the  large  intestine.  If  the  ulcers  heal,  the 
intervening  islets  of  mucous  membrane  become  so  much  more 
prominent  that  they  may  resemble  true  polypi.  Contraction  may 
lead  to  stenosis,  but  experience  shows  that  this  is  not  of  frequent 
occurrence.  It  only  exceptionally  happens  that  dysenteric  ulcers 
perforate,  for  the  serous  coat  over  them  is  usually  thickened  by 
inflammation.  In  less  pronounced  cases  the  intestine  shows  only 
the  signs  of  a  severe  catarrh  with  swelling  or  suppuration  of  the 
follicles,  or  the  formation  of  simple  catarrhal  ulcers.  Between  these 
there  exist  a  great  variety  of  transition  forms  which  sometimes  fol- 
low the  type  of  catarrhal  enteritis,  and  sometimes  of  true  dysentery. 

Syphilitic  ulcers  are  extremely  rare  in  the  small  intestine  (they 
are  most  frequent  in  the  newborn);  they  are  more  common,  but 
still  rare,  in  the  large  intestine  ;  they  are  most  common  in  the  rec- 
tum. Syphilitic  ulcers  of  the  large  intestine  are  usually  formed  by 
the  breaking  down  of  gummata  in  the  mucous  or  submucous  coats. 
They  begin  as  superficial  bulbous  elevations,  which  break  dov^oi 
slowly  and  leave  ulcers  characterized  by  sharp  borders  and  a  yellow- 
ish, flocculent,  grayish-white  base.  Under  certain  conditions  they 
may  coalesce,  v^th  extensive  loss  of  substance,  the  tendency  being 
to  superficial  rather  than  deep  ulceration.  Perforation  into  the 
abdominal  cavity  of  a  syphilitic  ulcer  of  the  large  intestine  has  not, 
as  far  as  I  know,  been  described,  but  perforation  into  some  neigh- 
bouring organ,  especially  from  the  rectum,  is  not  at  all  infrequent. 
Stenosis  of  the  large  intestine  from  syphilis  is  very  rare.  For 
syphilitic  ulceration  of  the  rectum,  see  the  chapter  on  Diseases  of 
the  Rectum. 

Amyloid  ulcers^  according  to  some  authors,  are  rare,  and  accord- 
ing to  others  (Colberg,  Courtois-Sufiit,  etc.)  they  are  frequent. 
The  pathological  anatomists  (Orth,  Ziegler,  Birch-Hirschfeld)  speak 


ULCERS  OF  THE  INTESTINES  26Y 

witli  great  reserve  concerning  the  occurrence  of  this  form  of  ulcer. 
At  the  present  time  they  have  no  clinical  importance. 

Embolic  or  thrombotic  ulcers  arise  from  the  occlusion  of  small 
twigs  of  the  mesenteric  artery,  as  a  result  of  endocarditis  or  of 
atheroma  of  the  large  vessels.  A  small  hemorrhagic  infarct  re- 
sults from  the  embolism,  and  is  followed  by  necrosis  and  ulceration. 
The  ulcers  are  located  chiefly  in  the  small  intestine,  from  the  duode- 
num down  to  the  caecum  ;  below  this  point  they  are  very  seldom  met 
with.  The  ulcers  are  of  various  sizes,  depending  upon  the  extent 
of  the  infarction.  Sometimes  the  ulceration  is  very  considerable, 
extending  through  the  entire  thickness  of  the  intestinal  wall,  and 
perhaps  leading  to  perforation  into  the  abdominal  cavity.  Septic 
emboli  from  ulcerative  endocarditis  may  cause  either  small  hemor- 
rhages or  very  minute  embolic  abscesses  between  the  mucous  and 
submucous  layers.  These  rupture  into  the  interior  of  the  intestine, 
and  give  rise  to  multiple  ulcerations. 

Symptomatology  of  Intestinal  Ulcee 

The  symptoms  of  intestinal  ulcers  are  very  varied,  and  depend 
not  only  upon  the  kind,  but  upon  the  localization,  the  number, 
and  the  extent  of  the  ulcerative  processes.  It  must  be  kept  in 
mind  that,  as  a  rule,  a  more  or  less  intense  catarrh  accompanies 
every  form  of  ulceration.  The  changes  in  the  stools  thus  produced 
(constipation,  diarrhoea,  mucous  stools,  bloody  stools)  in  turn  favour 
the  progress  of  the  ulceration  and  hinder  cicatrization.  We  have 
therefore  to  consider  a  variety  of  conditions  which,  to  a  very  con- 
siderable degree,  must  influence  and  modify  the  cHnical  picture  of 
intestinal  ulceration.  In  the  first  place,  there  are  no  distinctive  signs 
for  the  differentiation  of  the  various  kinds  of  ulcers.  Even  the 
recognition  of  tubercle  bacilli  in  the  stools — to  repeat  what  we  have 
already  emphasized  (page  120) — has  only  a  very  limited  significance. 
For  this  reason  a  separate  symptomatology  of  the  various  forms  will 
be  omitted,  and  the  discussion  will  be  limited  to  the  characteristics 
which  they  possess  in  common. 

It  is  undoubtedly  true  that  ulceration  frequently  occurs  without 
any  symptoms  whatever.  Every  physician  who  has  been  present 
at  many  autopsies  in  cases  of  phthisis  has  observed  intestinal  ulcera- 
tion, sometimes  of  considerable  extent,  which  had  caused  no  appre- 
ciable symptoms  during  life.  This  is  also  true  of  amyloid  degen- 
eration of  the  intestine  with  ulceration,  and  especially  so  for  stercoral 
ulcers,  as  well  as  for  the  catarrhal  and  follicular  forms.     It  is  diffi- 


268  DISBASES   OF   THE  INTESTINES 

cult  to  determine  whether  there  may  not  have  been  shght  subjective 
symptoms  (constipation),  and  changes  in  the  stools  (admixture  with 
blood,  mucus,  or  pusj.  The  clinical  history  gives  us  httle  positive 
information.  In  the  majority  of  cases  of  ulceration,  however,  there 
are  symptoms  which  j)ermit  the  diagnosis  to  be  made  in  some  cases 
with  likelihood,  and  in  others  with  certainty. 

We  shall  next  describe  : 

{a)  The  Subjective  Symjjtoms. — The  most  important  symptom  is 
pain.  As  has  just  been  mentioned,  pain  may  be  entirely  absent  in 
ulcer  of  the  intestine.  "When  it  is  present,  it  does  not  give  us  any 
clew  to  the  variety  or  location  of  the  ulcerative  process.  Though 
the  patient  be  intelligent,  his  statements  as  to  the  subjective  sensa- 
tions of  pain  are  very  vague,  and  it  is  only  exceptionally  that  they 
serve  to  indicate  the  location  of  the  process.  The  objective  sensi- 
tiveness on  pressure  is  more  valuable.  This  tenderness  seems  to 
me  to  be  most  marked  in  severe  forms  of  intestinal  tuberculosis, 
and  in  some  cases  I  have  found  it  localized  and  very  persistent  in 
the  region  of  the  umbilicus.  It  has  to  be  distinguished  from  the 
tenderness  of  chronic  dysentery,  which  is  more  diffuse  and  extends 
over  the  descending  colon  and  sigmoid  flexure.  In  my  experience 
this  too  may  be  absent.  The  intensity  of  the  pain  is  of  some  impor- 
tance in  estimating  the  extent  of  the  ulcer  and  the  progress  which 
it  is  making  toward  the  external  surface  of  the  intestine.  In  cases 
of  very  decided  tenderness  deep  ulceration  may  with  circumspection 
be  thought  of. 

(h)  The  Objective  Symjjtoms. — Of  these,  the  nature  and  condi- 
tion of  the  evacuations  from  the  bowels  are  of  chief  importance. 

In  cases  of  well-marked  ulceration  of  the  bowel  the  passages  may 
be  normal,  or  there  may  be  constipation.  It  is  important  to  re- 
member this  in  passing  judgment  on  individual  cases. 

The  younger  Frerichs  describes  two  very  instructive  cases  in  his  Contribu- 
tions to  the  Study  of  Tuberculosis  (1882).  They  were  both  cases  of  pulmonary 
consumption.  One  of  them  had  a  profuse  diarrhoea  with  elevation  of  tempera- 
ture, so  that  a  diagnosis  of  typhoid  was  made.  The  other  patient  was  persist- 
ently and  obstinately  constipated.  In  both  cases  the  autopsies  showed  that  the 
cause  of  the  bowel  symptoms  was  a  widespread  intestinal  tuberculosis.  In  the 
second  case,  in  addition  to  the  tuberculosis  of  the  ileum,  there  was  exten- 
sive tuberculous  ulceration  of  the  colon. 

JS^othnagel  advances  a  plausible  hypothesis  to  account  for  these 
cases,  viz.,  that  the  destructive  process  has  either  completely  de- 
stroyed the  nerves  in  the  base  of  the  ulcer,  or  that  the  continuous 


ULCERS   OF   THE   INTESTINES  269 

irritation  has  exhausted  their  sensitiveness  to  the  usual  stimuli.  The 
stools  usually  show  marked  deviations  from  the  normal ;  there  is 
diarrhoea,  or  diarrhoea  alternating  with  constipation.  It  is  very 
probable  that  the  seat  of  the  ulceration  has  an  influence  in  deter- 
mining which  of  these  conditions  will  predominate,  since  experi- 
ence has  shown  that  diarrhoea  is  less  frequent  when  the  ulceration 
occurs  high  up  than  when  it  is  below  the  ileum.  As  has  already 
been  said,  the  existence  of  a  simultaneous  enteritis  has  an  extremely 
important,  perhaps  the  most  important,  influence.  For  instance, 
there  is  scarcely  ever  any  severe  diarrhcea  in  ulcer  of  the  duodenum, 
because  the  process  is  a  localized  one,  and  therefore  the  catarrhal 
condition  is  limited  to  a  very  small  portion  of  the  intestine. 

The  presence  of  abnormal  constituents,  such  as  blood,  pus,  and 
shreds  of  necrotic  tissue,  is  more  important  than  the  consistence  of 
the  stools.  Blood  may  be  present  in  various  forms :  as  fresh  or 
decomposed  blood,  or  intimately  mingled  with  the  dejections,  yet 
recognisable  by  the  eye,  or,  Anally,  only  to  be  detected  by  the  micro- 
scope. The  old  maxim  that  blood  from  the  upper  part  of  the  intes- 
tinal canal  is  materially  altered  in  appearance  when  voided  is  true, 
as  a  rule,  in  ulceration  of  the  intestine.  But,  as  every  one  knows 
from  the  pathology  of  typhoid  ulcer,  blood  which  is  unchanged  may 
come  from  the  subdivisions  of  the  small  intestine,  provided  it  is 
quickly  expelled.  Blood  is  always  passed  in  an  unchanged  condi- 
tion when  it  comes  from  the  lower  part  of  the  small  intestine  or 
from  the  colon,  and,  according  to  the  amount  of  the  hemorrhage, 
appears  as  an  enterorrhagia,  or  is  intimately  mingled  with  the 
dejections.  Smaller  hemorrhages  are  usually  easily  recognised  in 
the  same  way ;  minute  ones  only  by  microscopic,  chemical,  or  spec- 
troscopic methods. 

Hemorrhages  are  not,  however,  a  necessary  symptom  of  intes- 
tinal ulcer.  In  dysenteric  and  typhoid  ulcers  they  are  very  fre- 
quent, and  in  tuberculous  and  catarrhal  ulcers  relatively  infrequent. 
In  tuberculosis  of  the  intestine,  according  to  Girode^^,  the  stools 
often  have  a  dark  colour,  similar  to  the  coffee-ground  vomit  of  gas- 
tric cancer ;  and  this  he  attributes  to  repeated  oozing  of  blood  from 
the  ulcerations.  I  have  observed  the  same  appearances,  but  they 
do  not  afford  conclusive  proof  of  the  presence  of  blood. 

Admixture  of  pus  in  the  fseces  is  a  very  important  symptom  of 
intestinal  ulcer.  However,  the  finding  of  pus  is  not  absolutely  con- 
clusive, since  it  may  come  from  some  abscess  in  the  neighbourhood 
which  has  ruptured  into  the  bowel,  or  may  occur  in  croupous  or 


'270  DISEASES  OF   THE   INTESTINES 

dysenteric  conditions,  or  from  ulcerating  tumours  of  the  bowel. 
For  this  reason,  as  I  know  from  personal  experience,  the  diagnosis 
may  become  extremely  difficult.  It  is  very  important  to  ascertain 
whether  the  pus  is  voided  pure  or  mixed  with  blood.  In  the  former 
■case  it  points  to  the  presence  of  an  abscess  adjacent  to  the  intestine, 
while  in  the  latter  it  indicates  that  the  pus  has  originated  in  the 
bowel  itself.  Aside  from  this  consideration,  it  may  be  stated  that 
the  presence  of  pus  makes  intestinal  ulceration  in  the  highest  degree 
probable.  On  the  other  hand,  its  absence  does  not  negative  the 
■existence  of  ulceration. 

Like  the  gastric  contents  in  ulcerating  carcinoma,  the  passages 
acquire  a  penetrating  fetid  odour  when  mixed  with  large  quan- 
tities of  pus.  This  differs  so  characteristically  from  the  normal 
odour  of  the  faeces  that  it  can  scarcely  be  forgotten  by  one  who 
has  ever  appreciated  it.  The  importance  of  this  sign  lies  in  the 
fact  that  purulent  stools  may  often  be  detected  in  this  way  when  a 
iormal  inspection  has  been  neglected.  In  many  cases  the  unaided 
eye  suffices  to  determine  the  presence  of  pus.  Small  quantities  of 
pus  can  only  be  recognised  by  the  microscope ;  but,  if  the  fseces 
are  spread  out  on  a  black  dish,  yellowish-green  specks,  of  the  size 
of  the  smallest  millet  seeds,  will  sometimes  be  seen  and  recognised 
as  pus. 

Fragments  of  intestinal  tissue^  when  present,  are  always  the 
result  of  necrotic  processes,  and  are  found  only  in  acute  and  sub- 
acute dysentery.  It  has  often  been  asserted  that  the  presence  of  a 
formation  resembling  frog  spawn  or  sago  grains  is  characteristic  of 
intestinal  ulceration.  But  there  is  now  no  doubt  that  Yirchow  was 
right  when  he  declared  that  these  are  vegetable  products,  which 
may  be  found  in  the  stools  in  a  great  variety  of  conditions.  Of  the 
intestinal  bacteria,  the  tubercle  bacillus  is  the  only  one  which  has 
any,  and  even  that  a  very  limited,  significance.  In  the  General 
Section  we  have  discussed  the  diagnostic  value  of  the  presence  of 
the  tubercle  bacilli,  and  it  is  sufficient  to  repeat  that  it  is  only 
their  continuous  absence  from  the  sputum  and  constant  presence 
in  large  numbers  in  the  stools  which  justifies  any  positive  conclu- 
sion. In  tuberculosis  of  the  rectum  a  doubtful  diagnosis  may  be 
made  certain  by  the  removal  of  material  containing  bacilli  from 
the  ulcer  itself. 

(c)  Meteorism. — This  may  accompany  intestinal  ulceration,  and 
is  seen  fairly  often  in  tuberculosis  of  the  bowel  and  in  dysentery. 
In  other  forms  of  ulceration  I  have  not  found  meteorism  a  con- 


ULCERS  OP   THE   INTESTINES  2Yl 

stant  symptom,  unless  there  existed  also  some  narrowing  of  the 
lumen  of  the  bowel.  In  the  above-mentioned  varieties  (e.  g.,  tuber- 
cular and  dysenteric  ulceration)  meteorism  may,  of  course,  be  con- 
sidered a  sign  of  intestinal  paresis. 

{d)  Fever. — Fever  is  not  present  in  simple  ulceration  of  the 
intestine — i.  e.,  in  the  catarrhal  or  follicular  forms.  But  irregular 
fever  is  a  very  important  clinical  symptom  of  dysenteric  and  tuber- 
cular ulcers.  Sloughing  carcinomata,  as  has  been  mentioned  in  the 
chapter  on  that  subject,  may  cause  an  irregular  and  sometimes  very 
marked  pyrexia ;  the  same  is  true  of  para-intestinal  abscesses. 

(e)  The  Urine. — Up  to  the  present  time  the  examination  of  the 
Tirine  has  not  been  of  any  special  importance.  The  interesting  rela- 
tion that  exists  between  ulceration  of  the  intestine  and  albumosuria 
after  the  administration  of  peptone  in  tubercular  ulceration  of  the 
intestine  (see  page  135)  is  worthy  of  further  investigation.  Under 
some  circumstances,  the  Ehrlich  diazo  reaction  may  be  of  service  in 
differential  diagnosis  (see  p.  276). 

{f)  The  general  health  may  suffer  markedly  from  the  fever, 
hemorrhages,  and  suppuration,  as  well  as  from  the  diarrhoea.  I 
have,  however,  seen  patients  who,  in  spite  of  frequent  suppurations, 
remained  well  nourished.  That  this  feature  depends  chiefly  on  the 
primary  cause  needs  no  explanation. 

The  symptomatology  of  ileo-ccecal  tumours  may  be  introduced 
in  this  place. 

The  age  and  sex  are  of  importance.  According  to  Conrath's 
collection  of  85  cases,  the  frequency  of  tuberculosis  of  the  caecum  is 
pretty  nearly  the  same  in  both  sexes.  Much  more  than  one  half 
(65  per  cent)  of  the  cases  were  between  the  ages  of  twenty  and  forty 
years.  Yery  few  were  found  in  the  fifth  and  sixth  decades.  From 
-Oonrath's  statistics  there  is  a  significant  preponderance  of  females 
between  the  ages  of  twenty  and  thirty,  while  in  those  between  thirty 
and  forty  the  proportion  of  males  is  markedly  greater.  Csecal  tuber- 
culosis usually  begins  insidiously,  or  has  no  characteristic  symptoms. 
There  may,  for  example,  be  constipation,  alternating  perhaps  with 
diarrhoea,  but  there  is  nothing  to  indicate  that  an  incurable  destruc- 
tive process  has  begun.  There  is  no  change  in  the  picture  until  the 
characteristic  phenomena  of  stenosis  or  a  tumour  become  manifest. 
The  distinctive  signs  of  chronic  stenosis  of  the  bowel  develop — the 
•occasional  attacks  of  colic  with  nausea  or  vomiting,  the  visible 
tetanic  contractions  of  the  intestine,  the  constipation  persistent  in 
spite  of  the  usual  remedies,  and,  as  a  result,  a  severe  loss  of  nutri- 


2Y2  DISEASES   OP  THE  INTESTINES 

tion.  In  prolonged  cases  the  marasmus  is  as  marked  as  the  cachexia 
of  cancer.  Occasionally  there  may  be  hemorrhages  from  the  bowel, 
or  blood  may  be  mixed  with  the  stools.  As  the  disease  is  usually 
associated  with  a  manifest  or  incipient  pulmonary  phthisis,  irregu- 
lar fluctuations  of  temperature  are  frequently  observed. 

The  most  important  symptom  of  caecal  tuberculosis  is  the 
t  u  m  our.  Its  size  varies  ;  it  is  usually  made  more  accessible  to 
palpation  by  filling  the  rectum  with  water.  At  fii-st  the  tumour  is 
more  or  less  movable,  but  later  it  may  become  quite  fixed  by  adhe- 
sions or  thickening  of  the  mesentery.  Under  such  conditions  it 
may  lie  immediately  under  the  abdominal  wall,  and  thus  lead  to 
serious  mistakes  in  diagnosis.  Furthermore,  it  may  suppurate, 
break  down,  and  ruj)ture  externally,  forming  an  artificial  anus ;  or 
the  abscess  may  perforate  into  the  abdominal  cavity,  or  into  one  of 
the  neighbouring  organs. 

The  course  of  caecal  tuberculosis  is  usually  slow.  Many  cases 
lasting  two  or  three  years  have  been  observed.  As  the  tumour 
doubtless  has  a  long  period  of  latency,  the  beginning  of  the  disease 
evidently  dates  much  farther  back. 

Under  medical  treatment  the  prognosis  is  unfavourable.  The 
stenosis  of  the  bowel  gradually  increases  until  there  is  absolute 
obstruction  or  perforation  into  the  abdominal  cavity  or  adjacent 
organs.  Death  may  be  caused  by  pulmonary  phthisis,  peritoneal 
tuberculosis,  by  disseminated  tuberculosis  of  the  intestine,  by  the 
protracted  suppuration  of  multiple  abscesses,  by  amyloid  changes  in 
the  intestines  or  kidneys,  or  by  other  complications. 

Diagnosis  an^d  Differential  Diagnosis 

The  detection  and  identification  of  ulcers  of  the  intestine  pre- 
sent many  difficulties.  One,  already  alluded  to,  is  that  many  forms  . 
run  a  perfectly  latent  course  or  give  but  slight  clinical  symptoms. 
A  second  difficulty,  which  has  also  been  mentioned,  is  that  the  dif- 
ferent forms  have  no  specific  characteristic  signs.  With  few  excep- 
tions, a  positive  diagnosis  can  only  be  made  when  the  other  clinical 
facts  clearly  show  the  relationship  between  and  etiology  of  the  symp- 
toms. On  the  other  hand,  it  occasionally  happens  that,  although 
the  standard  symptoms  are  absent,  one  may  suspect  ulceration  of 
the  intestine  when  disorders  of  the  functions  of  the  bowels,  pro- 
nounced tenderness,  diarrhoea,  and  marked  impairment  of  the  general 
health  are  suddenly  or  gradually  added  to  the  previous  symptoms. 
Even  in  such  a  case,  however,  the  disease  may  only  be  suspected. 


ULCEES   OF   THE   INTESTINES  273 

The  recognition  of  ulcers  of  the  small  intestine,  especially  those 
which  are  not  tuberculous,  is  especially  difficult.  The  changes  in 
the  stools  may  perhaps  consist  in  hemorrhage  or  melsena.  The 
presence  of  pus  can  not  be  depended  u]3on  because,  as  von  Leube  ^ 
has  shown,  pus  loses  its  characteristic  appeai'ance  in  passing  through 
the  colon.  It  is  unnecessary  to  say  that  hemorrhages  from  the 
intestinal  canal  may  have  a  great  variety  of  causes.  In  a  few  cases, 
as  in  those  reported  by  Nothnagel  ^^,  the  diagnosis  of  embolic  and 
thrombotic  ulcers  has  been  successfully  made,  and  is  of  course  pos- 
sible when  the  source  of  the  embolus  can  be  clearly  traced.  This 
may  be  possible  when  endocarditis,  pyaemia,  or  arterial  sclerosis  has 
preceded,  or  when  the  symptoms  of  embolism  of  a  branch  of  the 
mesenteric  artery  (severe  colicky  pains,  severe  hemorrhage  setting 
in  at  once,  meteorism,  intestinal  paralysis)  have  been  present  and, 
what  is  of  course  very  rare,  have  abated. 

The  prospect  of  recognising  ulcers  of  the  large  intestine  (ex- 
clusive of  the  rectum)  is  better,  because  the  excreted  products  are 
accessible  to  direct  and  repeated  examination.  Aside  from  the 
changes  in  the  consistence  of  the  stools  and  the  local  pain  and  ten- 
derness (whose  value  must  be  estimated  with  care),  the  main  factors 
to  be  looked  for  are  admixtures  of  blood,  pus,  mucus,  and  tissue 
debris  with  the  faeces.  Naturally,  the  presence  of  both  blood  and 
pus  is  of  the  highest  importance,  while,  as  already  explained,  either 
of  them  alone  leaves  room  for  many  possibilities.  The  diagnosis 
is  not  complete  until  not  only  the  presence  of  an  ulceration  is  de- 
termined, but  its  special  causation  made  out.  In  a  few  instances, 
in  addition  to  pulmonary  tuberculosis,  dysentery,  and  typhoid  fever, 
there  are  no  special  difficulties  in  reaching  a  conclusion,  but  there 
are  varieties  which  present  insurmountable  difficulties. 

I  shall  relate  one  case  in  which  the  diagnosis  of  tuberculous 
ulceration  of  the  large  intestine  was  probable,  and  another  in  which, 
although  ulcer  of  the  intestine  was  diagnosed  with  positiveness,  the 
etiology  of  the  ulcer  was  never  cleared  up. 

Case  I. — Miss  Clara  St.,  of  Radenickel,  near  Crossen  ;  twenty-eight 
years  old. 

Previous  History. — Father  had  chronic  pulmonary  disease — otherwise  no 
hereditary  taint  could  be  made  out.  The  patient  has  been  weak  and  sickly 
from  her  youth.  Began  to  menstruate  at  fourteen;  is  regular,  with  very  profuse 
flow.  Six  years  ago,  without  any  exciting  cause,  in  particular  without  any 
previous  cough,  moderate  haemoptysis.  This  was  repeated  every  four  to  six 
weeks.  Two  years  later  began  to  have  pains  in  the  epigastrium,  which  her 
physician  attributed  to  gastric  ulcer.     She  was  sent  to  Carlsbad.     Here  she 


274:  DISEASES  OP  THE  INTESTINES 

had  hemorrhages  from  the  stomach  and  melsena.  In  the  following  year 
hsemoptj'sis  returned  every  four  to  six  weeks.  No  change  occurred  until  Oc- 
tober, 1896,  since  which  time  there  has  been  no  hsemojjtysis. 

The  present  illness  developed  shortly  before  Christmas,  1897.  It  begaa 
with  a  sudden  attack  of  severe  pain  in  the  region  of  the  umbilicus,  lasting  day 
and  night,  not  dependent  upon  the  ingestion  of  food,  and  increased  by  pres- 
sure. Six  weeks  later  there  was  a  sudden  discharge  of  pus  from  the  rectum, 
preceding  a  normal  passage.  The  pus  coated  the  faecal  masses  superficially. 
This  discharge  of  pus  was  repeated  four  weeks  later,  the  pains  having  mean- 
while ceased.  From  that  time  on  evacuations  of  pus  continued  at  intervals  of 
four  to  six  weeks.  During  this  period  there  were  attacks  of  pain  in  the  region 
of  the  intestines,  but  not  simultaneously  with  the  purulent  discharge.  These 
attacks  used  to  last  for  a  few  weeks  and  then  disappear  for  a  few  months. 

Since  May,  1898,  the  purulent  discharge  has  been  constant.  There  has  been 
a  normal  painless  stool  every  day.  There  ai-e  frequent  cramplike  pains,  occur- 
ring only  at  night.  By  the  end  of  May,  bright  fluid  blood  began  to  appear 
with  the  pus.  This  gradually  increased  in  amount.  Since  the  middle  of  June, 
1898,  the  stools  have  been  preceded  by  clear  blood,  and  followed  by  blood  witk 
a  little  pus.     During  the  last  few  days,  neither  pus  nor  blood  has  been  passed. 

Present  Condition. — The  patient  is  poorly  nourished;  the  cheeks  and  lips- 
are  pale.  Pulse,  73,  of  moderate  tension.  No  fever.  Nothing  of  especial  in- 
terest in  the  lungs.  The  abdomen  shows  no  abnormal  resistance,  no  increased 
meteorism,  no  tenderness  anywhere.  Urine,  negative  ;  in  particular,  no  indi- 
can.     Examination  by  the  vagina  and  rectum,  negative. 

Stools,  solid  and  of  normal  calibre. 

Irrigation  of  the  bowel  gave  a  negative  result. 

On  June  30,  1898,  she  had  a  movement  consisting  of  well-formed  faecal 
masses  coated  with  muco-purulent  shreds,  in  which  pus  cells  were  demonstrated 
in  abundance  by  the  microscope.  Eepeated  examination  failed  to  show  tuber- 
cle bacilli.     Digital  and  ocular  examination  of  the  rectum  resulted  negatively. 

There  is  no  doubt  that  ulcers  were  present  in  this  case.  It  is 
most  probable  that  they  were  located  in  the  descending  colon  or 
the  sigmoid  flexure.  In  spite  of  the  absence  of  signs  of  pulmonary 
lesions  and  the  failure  to  find  bacilli,  the  diagnosis  of  tuberculous, 
ulceration  of  the  large  intestine  is  probable  from  the  previous  his- 
tory of  repeated  haemoptysis  and  the  hereditary  taint. 

Case  II. — Max  B.,  clerk;  age,  twenty-eight  years.  Was  perfectly  healthy 
until  1895.  In  July  of  this  year  he  acquired  gonorrhcea,  followed  by  stricture, 
which  was  treated  with  sounds  and  cured.  In  April,  1898,  had  another  attack 
of  gonorrhoea  which  lasted  three  weeks.  During  this  period  he  states  that  he- 
had  "catarrh  of  the  bladder."  He  had  a  chancre  at  the  same  time,  which 
lasted  fourteen  days.  Whether  this  was  a  soft  chancre  or  an  initial  lesion,  the 
patient  does  not  know  positively;  but,  at  any  rate,  he  was  treated  without 
mercurial  inunctions  by  a  specialist. 

As  early  as  January,  1897,  the  patient  noticed  for  the  first  time  bleeding 
from  the  bowel,  the  cause  of  which  he  does  not  know.     There  had  been  no. 


ULCERS  OF  THE  INTESTINES  2Y5^ 

antecedent  constipation  of  notable  degree.  During  this  period  he  had  twelve 
movements  from  the  bowels  each  day,  fluid,  and  mixed  with  blood.  He  does 
not  know  whether  they  contained  any  pus.  There  was  no  pain,  either  sponta- 
neous or  during  defecation;  and  the  actual  loss  of  blood,  in  his  opinion,  was 
less  than  at  the  present  time.  Under  the  treatment  which  the  patient  received 
from  January  until  July,  the  diarrhoea  gradually  ceased,  the  blood  continued  to 
appear  from  time  to  time,  even  when  the  stools  were  normal  otherwise,  and 
finally  even  this  ceased.  From  that  time  until  October,  1898,  he  had  no  abnor- 
mal symptoms.     The  treatment  was  by  internal  remedies. 

The  patient  now  appears,  complaining  that  he  has  four  to  five  diarrhoeal  pas- 
sages per  day  which  contain  blood  and  mucus.  He  has  tenesmus,  and  a  fluid 
resembling  bloody  mucus  frequently  escapes  without  faeces.  There  is  no  pain. 
He  has  a  good  appetite,  is  easily  satiated,  but  hunger  returns  in  a  short  time. 
However,  he  does  not  feel  in  any  wise  ill. 

Present  Condition. — A  moderately  well-nourished  young  man  of  slender  build,, 
who  looks  healthy.  An  examination  of  the  thoracic  viscera  shows  them  to  be 
absolutely  normal ;  there  is  no  ground  for  suspecting  pulmonary  phthisis.  The 
abdomen  is  nowhere  distended,  gives  no  abnormal  percussion  resonance,  and  is- 
nowhere  sensitive  to  pressure.  Digital  examination  of  the  rectum  gives  quite 
normal  results,  confirmed  by  repeated  visual  examination.  There  are  no  signs. 
of  syphilis.  There  is  no  swelling  of  the  glands,  no  leucoderma,  no  atrophy  of 
the  base  of  the  tongue,  and  there  are  no  nodules.  (In  response  to  an  inquiry, 
the  specialist  who  treated  the  case  in  1898  says  that  it  was  undoubtedly  a  soft 
chancre.)  The  urine  contains  neither  sugar,  albumin,  indican,  nor  peptones. 
The  patient  was  directed  to  bring  a  sample  of  his  passages  at  each  visit. 

The  examination  of  the  faeces,  which  was  made  on  an  average  two  or  three 
times  in  each  of  the  following  weeks,  showed  that  they  were  of  normal  colour, 
partly  formed,  but  mainly  pulpy.  There  was  a  slight  superficial  admixture  of 
bright-red  blood  and  a  large  admixture  of  greenish-yellow  pus  which  settled  in 
a  thick  layer  at  the  bottom  of  the  glass.  There  was  no  intimate  mingling  of 
the  pus  and  blood  with  the  faeces,  and  no  further  abnormal  changes  could  be 
made  out  upon  microscopic  examination.  Repeated  examinations  for  gonococci 
and  tubercle  hacilli  were  invariably  negative. 

The  treatment  consisted  at  first  in  suitable  diet,  all  irritating  substances, 
being  excluded.  Under  irrigation  with  chamomile  tea,  and  subsequently  with 
a  solution  of  tannic  acid,  the  diarrhoea  improved  somewhat,  but  the  blood  and 
pus  continued  in  variable  quantity.  There  was  no  pain,  either  spontaneous  or 
on  pressure.  Irrigations  with  a  solution  of  nitrate  of  silver,  1  to  1,000,  were  tried, 
but  had  to  be  abandoned  before  long  because  they  increased  the  diarrhoea,  and 
the  patient  complained  of  burning  sensations  in  the  rectum  and  sigmoid 
flexure.  Illumination  of  the  rectum,  the  patient  being  in  the  lithotomy  posi- 
tion, again  failed  to  give  any  positive  result. 

December  10,  1898. — The  blood  and  pus  in  the  stools  have  increased.  Pa- 
tient says  that  on  alternate  mornings  he  has  four  or  five  movements  of  the  bowels 
following  close  upon  each  other ;  they  contain  a  considerable  amount  of  pus; 
and  that  on  the  intervening  days  the  conditions  are  nearly  normal. 

December  18th. — Enema  of  subnitrate  of  bismuth  in  suspension,  preceded 
by  a  cleansing  enemata  of  chamomile  tea. 


276  DISEASES   OF   THE   INTESTINES 

JDeceniber  29th. — Has  only  one  or  two  movements  from  the  bowels  daily,  of 
thin,  pasty  consistence  and  still  containing  blood  and  pus  in  variable  quantity, 
but  always  enough  to  be  recognised  by  the  naked  eye. 

January  17^  1899. — Patient  feels  very  well.  One  or  two  movements  from 
bowels  daily.  They  still  contain  blood  and  pus,  but  in  smaller  quantity.  No 
pain.  Abdomen  not  tender  on  palpation  at  any  point.  Slight  meteorism  on 
jjercussion  below  the  umbilicus. 

In  this  case  also,  the  diagnosis  of  ulceration  of  the  large  intes- 
tine is  a  safe  one;  but  it  is  not  possible  to  determine  the  nature 
of  the  process  (whether  chi'onic  dysentery,  f  olKcular  ulcer,  or  tuber- 
culous ulcer).  There  could  not  have  been  a  follicular  or  catarrhal 
ulceration  at  the  bottom  of  this  case,  for  the  suppuration  was  too 
extensive;  and  there  was  besides  an  absence  of  a  long-continued 
antecedent  catarrh  to  act  as  a  predisposing  cause. 

In  the  diagnosis  of  ileo-ceecal  tuberculosis,  the  following  points 
should  be  considered  :  The  recognition  of  a  tumour  in  the  ileo- 
cecal region,  the  youth  or  middle  age  of  the  patient,  the  presence 
of  pulmonary  or  other  localization  of  tuberculosis,  a  long  duration 
of  the  symptoms,  emaciation  and  pallor,  the  presence  of  tuberculous 
processes  in  other  organs  (lungs,  joints,  etc.),  and,  finally,  the  exist- 
ence of  an  intestinal  stenosis  having  the  features  first  described  by 
König ^^.  They  are  the  following  :  The  abdomen  is  distended;  fre- 
quently there  is  visible  peristalsis,  accompanied  by  gurgling,  splash- 
ing, sometimes  musical  sounds,  especially  in  the  neighbourhood  of 
the  caecum.  Toward  the  end  of  an  attack  the  sounds  heard  resemble 
those  produced  by  expelling  the  last  drops  from  a  syringe ;  the  ab- 
domen collapses  and  the  attack  is  over.  According  to  König,  these 
peculiar  manifestations  depend  upon  the  relation  between  the  length 
and  the  tightness  of  the  stricture,  the  hypertrophy  of  the  portion  of 
the  intestine  above  the  constriction,  and  the  relaxation  of  the  gut 
below  it.  In  such  cases  Ehrlich's  diazo  reaction  gives  important 
confirmatory  evidence,  for  the  extended  investigations  of  Krokie- 
wicz^  have  demonstrated  that  this  reaction  is  almost  invariably 
negative  in  carcinoma  of  the  digestive  tract,  while  it  is  seldom 
absent  in  tuberculosis.  In  addition,  as  Obrastzow  ^^  has  shown,  the 
finding  of  tubercle  bacilli  may  fortify  the  diagnosis.  Aside  from 
carcinoma,  a  diiferential  diagnosis  must  take  into  consideration  the 
possibility  of  exudations  in  the  ileo-csecal  region,  especially  peri- 
typhlitis, and  also  various  rare  forms  of  tumour  (sarcomata,  fibrom- 
ata, foreign  bodies,  intussusception,  fsecal  tumours,  actinomycosis, 
pericolitis,  tumours  consisting  of  abnormally  located  or  displaced 


ULCERS  OF  THE  INTESTINES  277 

segments  of  the  bowel,  etc.).  It  is  impossible  to  enter  into  a  full 
discussion  of  all  these  sources  of  error,  and  these  hints,  although 
thej  by  no  means  exhaust  the  possibilities,  must  suffice.  The  dif- 
ferential diagnosis  between  carcinoma  and  tuberculosis  of  the  caecum 
calls  for  special  notice.  Experience  teaches  us  that  it  is  very  diffi- 
cult. None  of  the  above  criteria,  even  the  Unding  of  tubercle 
bacilli,  insures  us  against  error.  Only  a  collective  consideration  of 
the  signs  of  caecal  tuberculosis  warrants  a  decision.  The  following 
table  will  be  of  service,  though,  like  all  such  schematic  presenta- 
tions, it  has  only  a  limited  value  : 

Tuberculosis  of  the   Gceeum  Carcinoma  of  the  Ccecum 

Age :   Usually  the   second    to    fourth  Seldom  before  the  fourth  decade. 

decades. 

Duration :  Extremely  chronic.  Duration  that  usual  for  carcinoma. 

Lungs :  Frequently  more  or  less   pro-  Examination  of  the  lungs  negative. 

nounced  tuberculosis. 

T-MmöMr;  Considerable  extension  in  the  The    tumour    has   a   definite    outline, 

length  of  the  intestine ;  the  infiltra-  which  is  usually  strictly  limited  to 

tion  can  be  shown  by  palpation  to  that  of  the  caecum.     The  latter  can 

involve  the  bowel.  not  be  felt  as  such. 

Symptoms  of  stenosis :  Always  present ;  Symptoms  of  stenosis  may  be  entirely 

distinguished   by   remarkable   mur-  absent;   when   present,    are   usually 

murs.  less  pronounced  than  in  caecal  tuber- 
culosis. 

Condition  of  the  stools :  Blood  and  pus  Blood    and   pus  are   not   infrequently 

very  seldom ;  tubercle   bacilli   very  found ;  never  any  tubercle  bacilli. 

often  present. 

Fever :  Not  infrequently  observed.  Fever  exceptionally  present. 

Urine :    Ehrlich's    diazo    reaction    is  Diazo  reaction  always  negative. 

present. 

Tkeatmekt  of  Intestinal  Ulcees 

In  the  treatment  of  intestinal  ulcers,  other  than  those  of  the 
rectum,  the  curative  measures  at  our  command  are  few  in  number. 
The  weapons  which  asepsis  and  antisepsis  have  furnished  so  abun- 
dantly for  the  cure  of  external  ulcers  are  useless  in  the  treatment  of 
intestinal  ulceration.  Since  we  lack  an  agent  which  has  an  efficient 
and  lasting  influence  upon  the  intestinal  juices  and  the  intestinal 
contents,  we  can  not  even  fulfil  the  simple  postulate  of  nihil  nocere. 
The  only  thing  we  can  do  is  to  avoid  strong  irritants,  and  restore 
the  functions  which  have  been  perverted  by  the  ulceration  or  its 
accompanying  catarrh  to  normal. 

This  is  especially  true  of  ulcers  of  the  small  intestine,  and  among 
19 


278  DISEASES  OP  THE  INTESTINES 

these  of  tlie  tuberculous.  Here  our  chief  task  lies  in  the  control 
of  the  diarrhoea,  partly  by  diet  (see  page  224)  and  partly  by  the 
astringent  agents  already  described  (page  191).  We  again  call  at- 
tention to  the  favourable  action  of  the  preparations  of  chalk,  either 
alone  or  in  combination  with  bismuth  (dermatol,  beta-naphthol- 
bismuth,  etc.).  In  some  cases  of  severe  tuberculous  diarrhcea  in 
which  the  diagnosis  of  ulceration  was  made  with  as  much  positive- 
ness  as  it  can  be  at  the  present  day,  I  have  been  able  to  keep  the 
profuse  evacuations  at  least  temporarily  under  control  by  rest  in  bed 
and  anti-diarrhoeal  diet.  It  is  hardly  necessary  to  state  that  this 
treatment  is  sometimes  ineffectual. 

In  ulceration  of  the  large  intestine  the  results  are  more  favour- 
able, as  we  may  supplement  diet  by  direct  local  treatment  with, 
suitable  irrigations.  This  measure,  however,  should  not  be  valued 
too  highly,  since  the  agent  is  only  briefly  in  contact  with  the  dis- 
eased area,  and  the  reaction  of  the  bowel  to  various  drugs  is  found 
by  experience  to  be  very  much  increased.  Besides,  in  chronic  diar- 
rhoea it  is  not  possible  to  keep  the  intestine  in  a  clean  condition. 
These  are  all  factors  which  make  the  utility  of  local  treatment,  at 
least  in  severe  cases,  to  some  degree  problematic.  IS^evertheless,  the 
indication  in  every  case  is  to  try  suitable  disinfecting  and  astringent 
drugs :  such  are  boric  acid,  3  per  cent ;  salicylic  acid,  3  per  cent ; 
salicylate  of  soda,  5  per  cent ;  nitrate  of  silver,  0.2  to  0.5  to  1  per 
cent;  tannic  acid,  0,5  to  1  per  cent.  In  some  cases  I  have  seen 
decisive  results  from  bismuth  injections  given  in  similar  way  to 
Fleiner's  method  in  gastric  ulcer.  I  use  one  teaspoonful  to  one 
quarter  litre  of  water.  On  account  of  the  absence  of  any  irritating 
quality,  I  prize  this  drug  above  all  others,  and  recommend  that  it 
be  given  the  preference. 

The  treatment  of  ileo-cceoal  tuberculosis  is  surgical.  The  re- 
sults are  temporary,  of  course,  since  no  small  number  of  the  patients 
sooner  or  later  fall  victims  to  pulmonary  tuberculosis.  Of  86  cases 
reported  by  Conrath  ^*,  the  23  operated  on  were  found  to  be  in  good 
health  one  to  four  to  eight  years  later.  Judging  from  experience, 
the  dangers  of  the  operation  are  not  inordinately  high.  According 
to  Conrath,  in  86  operations  the  mortality  was  only  16  per  cent. 
The  surgical  procedures  that  have  been  tried  are  the  extirpation  of 
the  tumour  by  resection  of  the  intestinal  wall,  or  by  intestinal  anas- 
tomosis (after  Maisonneuve),  or  without  extirpation  the  complete 
exclusion  of  the  involved  segment  (division  of  the  ends  of  the  ex- 
cluded portion  of  gut  after  the  method   of   Salzer).     Experience 


ULCERS  OF  THE  INTESTINES  279 

shows  that  entero-anastomosis  offers  the  best  chance  of  recovery 
(Conrath's  statistics  give  10  cases  without  a  death),  and  the  results 
otherwise  are  equally  as  good  as  after  extirpation.  In  the  future  it 
should  be  the  operation  of  preference. 

LITERATURE 

1.  Klebs.     Pathologische  Anatomie,  1869,  Bd.  i,  S.  256. 

2.  von  Leube.     von  Ziemssea's  Handbuch,  Bd.  vii,  Abth.   2,  2te  Aufl.,  1878, 

S.  310. 

3.  Behrens.    Ueber  primäre  tuberculöse  Darminfection  des  Menschen.    Inaug.- 

Diss.,  Berlin,  1894. 

4.  Eisenhardt.    Ueber  Häufigkeit  u.  Vorkommen  d.  Darmtuberculöse.    Inaug.- 

Diss.,  München,  1891. 

5.  Wyss.     Correspondenzbl.  f,  Schweizer  Aerzte,  1893,  No.  22. 

6.  Melchior.     Cited  from  Virchow-Hirsch's  Jahresber.,  1890,  Bd.  i. 

7.  Hamann.     Statistik  der  Tuberculöse  im  Alter  von  16-19  Jahren.     Inaug.- 

Diss.,  Kiel,  1890. 

8.  Herxheimer.     Deutsch,  med.  Wochenschr.,  1885,  No.  52. 

9.  Orth.     Virch.  Arch.,  Bd.  Ixxvi,  1879. 

10.  Fischer.     Arch.  f.  experiment.  Pathol.,  Bd.  xx,  1886. 

11.  Dobroklonsky.     Arch,  de  Medecine  experim.,  1890,  No.  2. 

12.  Tschitschowisch.     Annales  de  l'Institut  Pasteur,  III  Annee,  No.  5,  p.  222. 

13.  "Wittstock.     Zur  Klinik   des  Ileus   durch   Darmtuberculöse.  Inaug.-Diss. 

Berlin,  1893. 

14.  Conrath.     Brun's  Beiträge  zur  klin.  Chirurgie,  Bd.  xxi,  Heft  1,  1898. 

15.  Billroth.     Cited  from  Conrath,  loc.  cit. 

16.  Pilliet.     Cited  from  Conrath,  loc.  cit. 

17.  Salzer.     von  Langenbeck's  Archiv,  Bd.  xliii. 

18.  Czerny,     Brun's  Beiträge  z.  klin.  Chirurgie,  Bd.  vi  u.  ix. 

19.  König.     Deutsche  Zeitschr.  f.  Chirurgie,  Bd.  xxxiv,  1892,  S.  65. 

20.  Körte.     Ibid.,  Bd.  xl,  1895,  S.  523. 

21.  Hofmeister.     Brun's  Beiträge,  Bd.  xvü,  S.  577,  1896. 

22.  Girode.     Contribution  a  l'etude  de  l'intestin  des  tuberculeux.     These  de 

Paris,  1888. 

23.  Nothnagel.     Darmkrankheiten,  S.  156. 

24.  Krokiewicz.     Wiener  klin.  Wochenschr.,  1898,  No.  29. 

25.  Obrastzow.     Arch.  f.  Verdauungskrankheiten,  Bd.  iv,  1898,  S,  440. 


CHAPTEE  XYI 

ROUND    TJLGEB   OF  THE  DUODENUM 

{Ulcus  rotundum  duodeni) 

Preliminary  Remarlcs. — Among  the  ulcerative  processes  of  the 
intestinal  canal  round  ulcer  of  the  duodenum  demands  careful  atten- 
tion— anatomically,  because  of  its  size  and  marked  characteristics ; 
clinically,  because  of  its  obscure  symptomatology  and  diagnostic 
signs ;  and  because  of  the  severe  complications  which  may  mark  its 
course  and  appear  with  an  extremely  acute  onset. 

In  its  most  important  features  the  pathological  anatomy  and 
pathogenesis  of  ulcer  of  the  duodenum  is  the  same  as  that  of  gastric 
ulcer.  The  extremely  voluble  discussion  which  followed  Cruveil- 
hier's  classic  presentation  of  the  latter  subject  has  not  solved  its 
numerous  problems.  With  reference  to  the  mode  of  origin  of 
chronic  duodenal  ulcer  we  also  are  obliged  to  fall  back  upon  more 
or  less  well-sustained  hypotheses. 

Referring  the  student  of  this  subject  to  the  text-books  on  dis- 
eases of  the  stomach,  as  well  as  to  the  monographs  of  Krauss  \  Chvo- 
stek^,  Boucquoy  ^,  Oppenheiraer^,  Eeckmann  ^,  and  Collin®,  we  shall, 
in  what  follows,  limit  ourselves  to  a  concise  description  of  the  most 
important  etiological  factors  which  we  have  gathered  from  literature 
and  from  our  own  experience. 

In  the  first  place,  just  as  in  the  case  of  gastric  ulcer,  so  pre- 
disposing and  immediate  causes  operate  in  the  production  of  the 
duodenal  ulcer.  As  regards  the  predisposing  causes,  it  is  univer- 
sally, and  I  believe  correctly,  held  that  the  corrosive  action  of  the 
gastric  acid,  which  is  not  neutralized  to  any  essential  degree  until 
it  meets  with  the  pancreatic  secretion,  plays  an  important  part. 
The  fact  that  round  ulcers  of  the  small  intestine  occur  almost  exclu- 
sively in  the  duodenum  permits  scarcely  any  other  explanation.  But 
there  are  other  predisposing  causes.  Dickinson ''',  and  shortly  after- 
ward Perry  and  Shaw  ^,  as  well  as  Marmaduke  Sheild  ^,  have  called 
attention  to  the  appearance  of  duodenal  ulceration  in  the  course  of 
380 


ROUND  ULCER  OF  THE  DUODENUM  281 

chronic  nephritis.  Thus,  from  the  Hterature  of  the  subject,  Perry 
and  Shaw  have  collected  70  cases  of  duodenal  ulcer,  in  no  less  than 
12  of  which  typical  Bright' s  disease  was  present.  In  such  cases 
everything  points  to  a  necrotizing  effect  exerted  by  the  retained 
urea  or  its  derivative,  amTnonium  carbonate.  It  is  apparent  that  in 
this  case  we  have  to  deal  with  the  same  influences  which  produce 
multiple  uraemic  ulcers  in  the  lower  segments  of  the  bowel.  The 
toxic  influence  may  act  continuously  or  suddenly,  perhaps  after 
extirpation  of  one  kidney,  or  after  a  severe  acute  nephritis  with 
suppression  of  urine. 

A  different  set  of  conditions  underlie  those  forms  of  duodenal 
ulcer  which  have  been  observed  after  extensive  burns,  after  frost- 
bite, and  in  erysipelas,  pemphigus,  and  septicaemia.  The  most 
likely  explanation  for  the  first-named  condition  seems  to  be  that 
soluble  fibrin  ferment  gains  access  to  the  circulation  and  emboli  are 
formed,  resulting  in  a  partial  necrosis  of  portions  of  the  duodenal 
mucous  membrane.  On  the  other  hand,  in  the  case  of  the  infective 
processes  named,  bacterial  influences  doubtless  play  an  essential 
role.  In  still  other  cases  a  traumatic  lesion  may  with  more  or  less 
probability  be  looked  upon  as  the  original  factor.  Such  cases  have 
been  observed  by  Schulze  ^°,  Brambillo^^,  Reckmann^,  J.  Pauly^^,  and 
others.  Thus  it  may  be  seen  that  very  varied  causes  may  operate  to 
produce  the  same  anatomical  changes,  and  it  is  of  importance  clin- 
ically to  discriminate  between  them. 

To  these  etiological  memoranda  may  be  added  a  few  brief  data  on 
the  age  and  sex  affected,  and  on  the  localization  of  duodenal  ulcers. 

As  far  as  age  and  sex  are  concerned,  the  duodenal  ulcer  shows 
striking  variations  from  gastric  ulcer.  Collin,  to  whom  we  owe  the 
most  complete  collection  of  cases  (2Y9),  gives  the  following  sum- 
mary : 

Under       10  years 42  cases. 

From  11-20  years 24  " 

"      21-30      "     43  '' 

"      31-40      "     52  " 

"      41-50      "     46  " 

"      51-60      "     41  " 

"      61-80      " 18  '' 

"      81-94      "     13  " 

Of  the  cases  occurring  in  the  first  ten  years  nearly  one  half 
(17)  belong  to  the  first  year  of  life.     Duodenal  ulcer  has  even  been 


282  DISEASES  OF  THE  INTESTINES 

observed  in  newborn  children  who  have  only  lived  a  few  hours,  so 
that  an  intra-uterine  origin  has  been  suspected.  Landau  ^^  has 
ascribed  them  to  thrombosis  of  the  umbilical  vein  and  embolism  of 
the  vessels  of  the  small  intestine,  with  consecutive  necrosis. 

The  infrequency  of  duodenal  ulcer  at  puberty,  its  slow  increase 
during  the  third  decade,  its  marked  rise  in  the  fourth  and  fifth, 
and  its  slow  falling  oif  again  in  the  sixth,  is  noteworthy. 

There  is  a  striking  unanimity  among  the  various  authors  as 
regards  the  preponderance  of  the  affection  among  the  male  sex. 
Collin  found  205  cases  out  of  257,  or  79  per  cent,  in  males.  This 
fact  is  one  of  the  most  striking  in  the  pathology  of  duodenal  ulcer. 
How  shall  we  explain  the  fact  that  the  male  sex,  which  has  so 
marked  an  immunity  from  round  ulcer  of  the  stomach,  should  show 
so  peculiar  a  predisposition  toward  duodenal  ulcer  ?  In  my  opinion 
the  explanation  can  only  be  found  in  the  difference  in  the  habits  of 
men  and  of  women.  Of  especial  importance  is  the  fact  that  the  use 
of  alcohol  and  tobacco  more  often  causes  a  chronic  gastritis  with 
marked  hyperacidity  in  men  than  in  women.  This,  however,  would 
not  explain  why  the  duodenum  becomes  the  favourite  seat  of  ulcer- 
ation. In  this  connection  the  following  considerations  appear  to 
me  to  be  worthy  of  notice. 

Through  investigations  on  dogs  made  by  von  Mering^^  and 
Moritz  ^^^  we  know  that  the  stomach  expels  water  into  the  intes- 
tine with  extraordinary  promptness ;  and  further,  that  alcohol,  sa- 
lines, dextrin,  and  acids,  although  they  are  absorbed  by  the  stomach, 
are  only  taken  up  by  it  to  a  very  limited  extent.  It  further 
appears,  from  the  investigations  of  von  Mering,  that  the  first  dis- 
charges contain  these  substances  in  very  concentrated  solution. 
When  von  Mering  poured  300  cubic  centimetres  of  25  per  cent 
alcohol  into  the  empty  stomach,  105  cubic  centimetres  of  10.5  per 
cent  alcohol  flowed  out  within  ten  minutes.  When  he  poured  200 
cubic  centimetres  of  50  per  cent  grape  sugar  solution  into  the 
empty  stomach,  the  fluid  which  was  carried  into  the  duodenum 
amounted  to  120  cubic  centimetres,  with  32  per  cent  sugar.  In 
addition,  we  know  from  Moritz's  investigations  that  the  stomach 
first  expels  the  fluid  portions  of  the  chyme,  while  the  sohd  portions 
follow  quite  slowly.  Furthermore,  the  stomach  protects  itself  from 
highly  concentrated  solutions  by  secretion  of  water ;  such  a  function 
has  not  yet  been  demonstrated  for  the  duodenum.  It  thus  follows 
that  the  duodenal  mucous  membrane  has  much  less  protection  against 
concentrated    watery  solutions   than  the    stomach,    whose  mucous 


ROUND   ULCER  OF  THE   DUODENUM  283 

membrane  is  relatively  well  protected  against  injury  during  the  first 
stage  of  digestion  by  the  slip]3ery  or  solid  contents.  If,  then,  acids, 
alcohol,  and  saline  solutions  act  upon  a  duodenal  mucous  membrane 
already  irritated  by  an  existing  hyperacidity,  it  only  needs  an  oppor- 
tune cause  to  produce  a  partial  necrosis  of  this  unresisting  tissue. 
This  explanation  receives  a  further  illustration  from  the  observa- 
tions of  Boucquoy  ^,  Burwinkel  ^^,  and  others,  which  I  can  confirm, 
that  ulcer  of  the  duodenum  occurs  with  especial  frequency  in  ha- 
bitual alcoholics.  If  I  might  cite  the  results  of  treatment  as  a  guide 
to  an  opinion  in  this  matter,  I  would  assert  that  duodenal  ulcer, 
although  not  always  in  classic  form,  is  a  very  prevalent  lesion  in 
alcoholics.  I  shall  return  to  this  point  in  the  section  devoted  to 
symptomatology  and  diagnosis. 

Among  the  features  worthy  of  notice,  we  would  call  attention 
to  the  fact  that  duodenal  ulcers,  like  gastric  ulcers,  are  usually 
single.  Out  of  233  cases  in  which  Collin  found  the  number  noted, 
the  ulcer  was  solitary  in  195  (83.6  per  cent).  Occasionally  duode- 
nal ulcer  is  found  associated  with  gastric  ulcer  or  with  esophageal 
ulcer.  In  the  great  majority  of  cases  the  ulcer  is  situated  in  the 
upper  part  of  the  duodenum  (242  times  in  Collin's  table  of  262  cases) ; 
in  not  a  few  (74)  it  was  adjacent  to  or  in  contact  with  the  pylorus ; 
in  14  cases  the  seat  was  the  descending  portion,  and  in  only  6  was 
it  found  in  the  inferior  horizontal  portion. 

There  is  a  discrepancy  in  the  statistics  as  to  the  relative  fre- 
quency of  involvement  of  the  anterior  and  the  posterior  wall. 
Oppenheimer  states  that  it  is  as  18  :  16.  Collin  found  that  out  of 
12T  cases  in  which  particulars  were  given,  the  ulcer  was  on  the 
anterior  wall  71  times,  on  the  posterior  wall  45  times,  on  the  upper 
edge  10  times,  and  only  once  on  the  lower  edge  ("  Bord  superieur  ou 
inferieur ").  In  the  descending  portion  the  inner  wall  was  most 
often  involved,  especially  in  the  immediate  vicinity  of  the  papilla. 

The  duodenal  ulcer  not  infrequently  gives  rise  to  numerous 
and  serious  complications,  which  will  be  comprehensively  considered 
further  on. 

Symptomatology  and  Diagnosis 

In  the  first  place,  it  is  to  be  noted  that  a  duodenal  ulcer  fre- 
quently runs  its  course  without  any  symptoms,  and  that  it  may 
cause  death  by  perforation  into  the  abdominal  cavity  at  a  time  when 
the  patient  seems  to  be  in  perfect  health.  Such  a  latent  course  is 
apparently  more  common  than  it  is  with  gastric  ulcer.     Whether 


284  DISEASES  OP   THE  INTESTINES 

in  siicli  cases  there  have  not  been  slight  symptoms  extending  back- 
ward over  perhaps  a  long  period  is  difficult  to  determine,  but  the 
fact  remains  that  perforation  is  seldom  preceded  by  severe  gastric 
or  intestinal  symptoms.  Such  cases  have  been  termed  acute  ulcers. 
The  symptoms  may  be  divided  into  subjective  and  objective. 

A.  Subjective  Symjptoms 

Pain. — The  pain  of  duodenal  ulcer  closely  resembles  that  of 
gastric  ulcer.  It  is  of  a  burning,  boring  character,  and  radiates 
downward  or  to  the  sides,  seldom  or  (as  Burwinkel  says)  never 
toward  the  back.  According  to  Oppenheimer,  the  pain  is  increased 
by  lying  on  the  right  side.  A  characteristic  feature  of  the  pain 
is  that  it  comes  on  several  hours  after  the  ingestion  of  food,  and  is 
localized  in  the  right  hypochondrium  at  a  point  on  the  prolongation 
of  the  parasternal  line  about  two  centimetres  below  the  gall  bladder. 
There  are  many  exceptions  to  this.  The  pain  may  be  more  to  the 
left  in  the  pit  of  the  stomach,  in  the  umbilical  region,  or  excep- 
tionally it  may  be  more  or  less  below  this  point.  Judging  from 
my  own  experience,  I  should  also  state  that  there  is  no  relationship 
between  the  nature  of  the  food  and  the  onset  of  the  pain,  and  also 
that  the  latter  may  persist,  even  begin  during  the  fasting  state — ^for 
example,  at  night. 

From  observations  which  he  made,  Chvostek  formulated  a  test 
which  might  serve  to  differentiate  duodenal  from  round  gastric 
ulcers.  He  found  that  pressing  gastric  pains  coming  on  two  and 
a  half  hours  after  breakfast  were  permanently,  and  similar  pains 
about  three  hours  after  dinner  were  temporarily  relieved  by  the 
taking  of  wine.  He  concludes  from  this  that  when  the  ulcer  is  in 
the  duodenum,  the  taking  of  the  wine  causes  a  reflex  closure  of  the 
pylorus,  and  thus  arrests  the  flow  of  the  gastric  contents  into  the 
duodenum.  This,  in  the  case  of  the  more  abundant  meal,  causes  a 
temporary  remission,  and  in  the  case  of  the  lighter  one  a  lasting 
relief.  But  if  the  ulcer  is  situated  in  the  stomach,  the  swallowing 
of  wine  not  only  does  not  relieve  the  pain,  but  increases  it.  Simi- 
larly Burwinkel  ^^  reports  a  case  in  which  "  pain  in  the  stomach," 
beginning  two  or  three  hours  after  each  meal,  was  relieved  by  the 
taking  of  an  acid  wine  or  citric  acid. 

With  certain  limitations  I  have  been  able  to  confirm  this  sign 
in  several  cases  of  duodenal  ulcer.  I  believe  that  it  is  dependent 
solely  upon  hyperacidity  of  the  gastric  juice,  for  we  know  that  in 
this  condition  the  ingestion  of  fluid  or  food  will  cause  a  cessation  of 


ROUND  ULCER  OF  THE   DUODENUM  285 

the  pain.  "Whetlier  this  comes  about,  as  Chvostek  thinks,  from  a 
reflex  pyloric  closure  which  for  the  time  being  prevents  the  passage 
of  the  food  into  the  duodenum,  or,  as  I  believe,  from  dilution  of 
the  superabundant  hydrochloric  acid  by  the  fluid  and  consequent 
diminished  irritation  of  the  ulcerated  surface,  may  be  left  an  open 
question.  At  any  rate,  it  seems  to  me  that  the  nature  of  the  fluid 
is  of  no  importance  except  that  substances  such  as  milk  or  egg  albu- 
min, which  have  a  strong  tendency  to  combine  with  hydrochloric 
acid,  should  act  better  than,  for  example,  wine. 

B.   Objective  Si/mptoms 

1.  Points  of  Tenderness. — The  typical  point  of  tenderness  on 
pressure  coincides  with  the  area  of  spontaneous  pain  above  described, 
but,  like  it,  may  exhibit  numerous  variations  which  may  easily  lead 
to  errors  in  diagnosis.  As  far  as  I  know,  a  dorsal  point  of  tender- 
ness has  never  been  observed.  In  several  cases  I  have  noted  a 
circumscribed  tender  point  to  the  right  of  the  spinal  column  and 
close  to  the  twelfth  dorsal  vertebra. 

2.  Yomiting. — When  the  pain  is  severe  and  long  continued  it 
may  lead  to  vomiting,  which  is  probably  of  a  reflex  nature.  Strange 
to  say,  there  are  only  scanty  allusions  to  this  symptom  in  recent 
literature.  Oppenheimer  found  it  noted  17  times  in  the  cases  (over 
100)  which  he  collected. 

The  accounts  given  by  older  authors  (Albers^''',  Mayer  ^^)  do 
not  agree  with  our  experience  of  to-day.  Krauss  more  correctly 
observes  (loc.  cit.,  p.  59) :  "  In  the  clinical  histories  which  I  have 
collected  it  [vomiting]  is  very  seldom  mentioned ;  it  depends  either 
upon  stricture  of  the  duodenum  or  is  the  result  of  cardialgia.  In 
a  few  cases  only  is  it  seen  in  connection  with  dyspeptic  phenomena." 
Starke  ^^  and  Boucquoy  ^  make  similar  statements.  My  own  experi- 
ence, as  far  as  it  is  possible  to  draw  conclusions  from  a  few  observa- 
tions, confirms  their  views. 

The  vomited  matter  has  been  variously  described.  In  one  ob- 
servation reported  by  Reckmann  ^,  which  in  my  opinion  is  open  to 
some  criticism,  the  vomiting  occurred  in  three  installments — the 
first  pale  and  watery,  the  second  bitter  and  sirupy  (bile),  and  the 
third  a  sweetish  mass  (blood).* 

3.  Intestinal  Hemorrhage  and  HoBmatemesis. — Profuse  hemor- 
rhages from  the  stomach  or  rectum  are  a  frequent  symptom  of 

*  See  under  head  of  the  Examination  of  the  Gastric  Contents  (in  Special  Part). 


286  DISEASES  OF  THE  IXTESTINES 

duodenal  ulcer  (perhaps  in  one  third  of  all  the  cases — Krauss,  Chvo- 
stek,  Oppenheimer).  It  is  probable  that  this  figure  is  too  low,  as 
many  of  the  smaller  hemorrhages  no  doubt  escape  observation. 
In  34  cases  of  hemorrhage  which  Oppenheimer  found  recorded, 
vomiting  of  blood  occurred  8  times,  malsena  10  times,  and  both 
hsematemesis  and  meleena  16  times.  In  all  the  severe  cases  symp- 
toms of  collapse  follow  the  escape  of  blood  by  the  mouth  or  the 
bowel.  When  very  copious  the  hemorrhage  may  be  the  imme- 
diate cause  of  death.  It  is  very  characteristic  of  duodenal  ulcer 
that  the  intestinal  hemorrhages  recur  at  fixed  intervals  coincident 
with  other  phenomena  of  the  ulceration. 

4.-  The  Comjposition  of  the  Gastric  Contents. — There  are  only  a 
few  observations  on  record  (von  Leube  ^'',  Reckmann  ^,  A.  Robin  ^, 
and  Devic  and  Roux^~).  In  the  first  two  there  was  a  condition  of 
subacidity.  In  the  last  mentioned,  a  case  accompanied  by  progres- 
sive pernicious  anaemia  and  profuse  diarrhoea,  there  was  hyper- 
chlorhydria.  The  latter  condition  was  present  in  one  of  my  cases, 
though  it  should  be  stated  that  the  examination  was  made  a  long 
time  before  the  occurrence  of  the  intestinal  hemorrhages.  Until 
more  observations  have  been  accumulated,  a  differential  diagnosis 
on  the  basis  of  the  results  of  examination  of  the  gastric  contents  is 
not  permissible  ;  the  same  opinion  is  expressed  by  von  Leube.  In 
three  cases  Robin  found  an  entire  absence  of  free  hydrochloric  acid, 
but  an  abundance  of  organic  acids.  Unfortunately  no  details  are 
given  as  to  the  kind  of  test  meal  used,  nor  of  the  motor  activity. 
I^evertheless  Robin's  results  are  very  remarkable. 

5.  There  is  nothing  characteristic  in  the  urine  or  the  dejections. 

6.  Icterus. — The  jaundice  which  has  been  observed  in  a  few 
cases  (according  to  Collin,  9  out  of  262)  is  not  a  specific  sign  of 
ulcer  of  the  small  intestine  ;  it  belongs  rather  to  the  complications 
(see  below). 

Of  all  these  symptoms,  not  one  jper  se  enables  the  diagnosis  to 
be  made  with  certainty  or  even  probabihty.  Only  the  ensemble,  the 
entire  clinical  history,  the  consideration  of  age  and  sex,  is  signifi- 
cant or  decisive.  Taking  into  consideration  all  of  these  symptoms 
(which  are  not  often  associated  in  a  single  case),  and  excluding  all 
other  possibilities,  the  diagnosis  of  an  ulcer  of  the  small  intestine 
may  be  clinically  made  with  some  degree  of  cei'tainty.  In  this  view 
I  agree  with  Chvostek,  Boucquoy,  and  Burwinkel,  but  there  are 
many  authors  who  are  of  a  different  opinion  (von  Leube,  Ewald, 
Eichhorst,  Nothnagel,  Collin).     It  is  indeed  pushing  scepticism  to 


ROUND  ULCER  OF   THE  DUODENUM  28Y 

the  limit  to  say,  as  does  Collin  in  his  otherwise  admirable  thesis,  that 
the  diagnosis  of  duodenal  ulcer  intra  vitam  is  impossible. 

What  I  have  just  said  will  be  illustrated  by  two  positive,  one 
probable,  and  one  doubtful  eases  of  duodenal  ulcer. 

1.  Secretary  of  Police  R.,  of  Berlin,  comes  from  a  healthy  family,  in  which 
haemophilia  has  never  been  observed.  No  history  of  any  previous  illness.  Took 
sick  about  twenty  years  ago  (1876)  with  anaemia  and  tarry  stools.  Previous  to 
that  time  there  had  been  gastric  and  intestinal  disorders.  The  patient  sub- 
sequently recovered,  and  aside  from  temporary  attacks  of  indigestion,  was  fairly 
well  until  1891.  At  this  time,  after  having  suffered  from  a  sense  of  oppression 
in  the  region  of  the  stomach,  he  suddenly  had  several  evacuations  of  very  black 
stools.  The  patient  fainted  at  the  time.  For  several  weeks  he  was  under  treat- 
ment at  the  Augusta  Hospital.  Following  this  there  was  a  long  period  of  good 
health,  although  from  time  to  time  there  were  attacks  of  pressure  in  the  um- 
bilical region  or  in  the  pit  of  the  stomach,  and  several  small  hemorrhages,  to 
which  little  notice  was  paid  by  the  patient.  Another  severe  hemorrhage  oc- 
curred in  1896,  also  with  syncope.  This,  like  the  other,  was  recovered  from. 
In  1897,  while  under  treatment  at  Carlsbad,  he  had  a  return  of  the  bleeding, 
which,  however,  did  not  last  very  long.  From  this  time  the  patient  never  fully 
recovered  his  health.  He  has  almost  constantly  a  feeling  of  pressure  and  weight 
in  the  stomach  and  abdomen,  not  dependent  upon  the  ingestion  of  food,  and 
suffers  from  frequent  eructations  which  are  sour,  but  never  putrefactive.  In 
November,  1897,  he  had  another  severe  hemorrhage.  During  the  summer  of 
1898  he  took  the  Wildungen  cure  for  a  catarrh  of  the  bladder.  In  October, 
1898,  had  tarry  stools  to  a  moderate  extent,  and  in  December,  1898,  a  severe 
hemorrhage.  These  were  always  preceded  by  a  sense  of  pressure,  fulness  in  the 
abdomen,  and  eructations  of  gas. 

The  patient  does  not  remember  ever  having  vomited  or  having  liad  severe 
pains  in  the  stomach  or  the  intestines.  The  appetite  has  generally  been  good, 
but  diminished  after  the  attacks. 

Present  condition  (abstract) :  Very  anaemic — general  nutrition  much  depre- 
ciated. Organs  of  circulation  and  respiration  normal.  Heart  sounds  clear, 
no  adventitious  sounds.  Abdomen  markedly  relaxed ;  the  integument  may  be 
raised  in  folds.  Under  suitable  illumination  the  stomach  is  appreciable ;  it  is 
apparently  displaced  downward,  giving  marked  splashing  sounds  as  far  as  three 
fingers'  breadth  below  the  umbilicus.  The  other  abdominal  conditions  are  nor- 
mal, and  in  particular  there  is  no  tenderness  either  in  the  region  of  the  stomach 
or  duodenum.     Examination  of  the  urine  shows  it  to  be  normal. 

2.  Oscar  S.,  dealer  in  wood,  Berlin,  thirty-seven  years  old.  The  patient's 
mother  was  a  chronic  sufferer  from  gastric  disorders,  and  was  extremely  emaci- 
ated when  she  died.  His  father  is  healthy.  Since  he  was  nine  years  old  the 
patient  has  suffered  from  digestive  troubles.  At  the  beginning  he  used  to  have 
occasional  pains  in  the  gastric  region,  coming  on  without  apparent  cause  and  last- 
ing a  quarter  to  half  an  hour.  His  appetite  was  good  and  the  bowels  regular. 
When  he  was  almost  thirty  years  old  the  pains  increased,  radiated  toward  the 
right  side,  especially  toward  the  back  and  to  the  right  shoulder  blade,  and 
became  more  frequent.     They  usually  came  on  three  to  four  hours  after  eating. 


288  DISEASES   OP   THE  INTESTINES 

occasionally  't\'hile  fasting,  and  very  often  during  the  night.  The  sort  of  food 
ingested  made  no  essential  difference,  for  the  pain  appeared  equally  after  either 
fluid  or  solid  diet.  Rest  in  the  dorsal  position  alleviated  the  pains,  while  active 
exercise  increased  them.  There  was  never  any  vomiting.  Appetite  and  bowels 
were  always  in  good  condition. 

Under  suitable  diet,  rest,  and  the  use  of  Carlsbad  water,  sometimes  at  the 
Springs  and  sometimes  in  Berlin,  his  condition  gradually  improved.  In  Janu- 
ary, 1896,  he  again  began  to  have  severe  pains  of  the  character  described 
above ;  they  extended  backward  and  came  on  several  hours  after  eating.  He 
always  felt  well  immediately  after  eating.  This  attack  was  followed  by  a 
slow  improvement.  In  January,  1896,  while  travelling,  he  had  a  sudden  pro- 
fuse JiemorrTiage  from  the  intestine.  The  blood  was  at  first  diluted  and  mixed 
with  faeces,  but  subsequently  there  was  clear  blood  of  coal-black  colour.  At 
the  same  time  there  was  extreme  prostration,  so  that  the  man,  who  was  of  her- 
culean build,  was  obliged  to  take  to  his  bed  and  remain  there  for  thirty-six 
hours.  He  was  treated  by  rest  in  bed,  and  poultices,  and  later  drank  Carlsbad 
Mühlbrunnen.  Improvement  was  rapid,  and  for  a  year  and  a  half  he  was  per- 
fectly well.  In  October,  1897,  the  pains  returned  in  the  right  side  several  hours 
after  eating,  and  were  relieved  by  the  ingestion  of  warm  food.  The  treatment 
for  ulcer,  carried  out  for  several  weeks,  was  again  followed  by  improvement. 
In  the  summer  of  1898  he  took  the  Carlsbad  treatment  with  good  results. 

The  examination  of  the  gastric  contents  on  two  occasions  showed  marked 
hyperacidity  (HCl  0.28-1.35  per  cent).  Besides  this,  there  was  a  characteristic 
tender  point  in  the  prolongation  of  the  right  parasternal  line.  At  the  last 
examination,  November,  1898,  the  duodenal  region  was  absolutely  free  from 
tenderness. 

3.  Joseph  L.,  bookkeeper,  born  in  Poland,  thirty-one  years  old.  The 
family  history  has  nothing  of  interest.  At  the  age  of  sixteen  the  patient  had 
typhoid  fever,  and  at  eighteen  cholerine.  Since  he  was  nineteen  years  old  he 
has  had  gastric  symptoms,  which  consisted  in  pressure  in  the  pit  of  the  stom- 
ach, frequent  eructations,  and  marked  constipation.  For  the  past  seven  or 
eight  years  he  has  had  hemorrhages  from  the  intestines,  as  he  says,  every 
spring  and  fall.  These  are  preceded  by  sudden  extreme  weakness,  nausea, 
perspiration,  and  a  desire  to  defecate.  The  first  movement  is  free  from  blood, 
but  those  which  follow  are  intimately  mixed  with  blood  of  a  coal-black  colour. 
Has  never  vomited  blood.  During  the  past  year  there  were  four  such  hemor- 
rhages. In  consequence  of  the  frequent  losses  of  blood  the  patient  has  become 
very  angemic,  and  has  not  recovered  from  them  as  he  used  to. 

From  the  notes  taken  when  he  w'as  seen  for  the  first  time,  only  the  follow- 
ing need  be  quoted:  Palpation  of  the  abdomen  shows  that  on  the  right  side 
above  the  umbilicus,  about  two  fingers'  breadth  below  the  region  of  the  gall 
bladder,  there  is  a  decidedly  tender  point,  while  the  corresponding  area  on  the 
left  side  is  absolutely  painless.  The  patient  identifies  this  point  as  the  seat 
of  his  pain,  which  is  pressing  in  character,  but  never  colicky.  Aside  from 
poikilocytosis,  no  changes  are  noted  in  the  examination  of  the  blood. 

It  is  perhaps  worth  recording  that  a  few  ova  of  the  trichina  spiralis  were 
observed,  but  this  probably  has  no  bearing  on  the  present  illness. 

4.  Mr.  v.,  member  of  the  Board  of  Accounts  of  Gross  Lichterfelde,  near  Ber- 


EOÜND  ULCER  OF  THE  DUODENUM  289 

lin,  forty-one  years  old.  Well  until  December,  1897.  Since  then,  without  any 
evident  cause,  he  has  had  a  sense  of  fulness  a  few  hours  after  meals.  An  exam- 
ination which  I  made  at  that  time  gave  absolutely  negative  results.  On  January 
6,  1898,  he  was  suddenly  taken  with  severe  syncope  and  melsena.  On  January 
7th  the  syncope  was  repeated.  On  January  8th,  after  drinking  milk,  there  was 
a  slight  vomiting  of  blood.  Rectal  feeding  was  resorted  to.  There  was  no 
further  hemorrhage.  Gradual  return  to  health.  Spent  three  months  partly  in 
the  sanitarium  and  partly  in  the  mountains. 

He  still  has  occasional  pains  on  the  right  side  of  the  median  line,  usually  a 
few  hours  after  eating  or  after  physical  exertion.  The  painful  area  varies  : 
it  may  be  more  to  the  right  or  toward  the  median  line,  and  may  even 
pass  over  to  the  left  side.  The  pain  is  cut  short  by  taking  more  food  or 
alkalies.  There  are  times  when  there  is  no  pain.  Appetite  good,  bowels 
confined.  Exaynination  shows  that  tJiere  is  no  sensitive  area  over  the  stomach, 
or  to  the  right  or  the  left  of  it,  nor  is  there  any  dorsal  tender  point. 

The  symptoms  of  the  first  and  second  eases  fulfil  all  the  require- 
ments for  an  exact  diagnosis.  The  chronic  course,  the  repeated 
attacks  of  hemorrhage  per  rectum,  and  the  absence  of  any  special 
dyspeptic  symptoms,  leave  scarcely  any  doubt  as  to  the  nature  of 
the  trouble.  The  diagnosis  of  the  other  two  cases  is  more  difficult. 
In  the  third,  the  repeated  attacks  of  melsena  without  any  special 
gastric  symptoms,  and  the  sensitiveness  on  pressure  to  the  right  of 
the  pylorus,  make  duodenal  ulcer  probable.  Some  of  the  other 
characteristic  symptoms,  such  as  occasional  pain  significantly  local- 
ized, are  absent,  so  that  some  doubt  remains. 

The  fourth  case  can  not  be  decided  offhand  with  any  certainty, 
because  the  painful  area  is  not  fixed,  the  objective  signs  are  absent, 
and  there  is  hsematemesis  as  well  as  melsena.  The  nature  of  the 
pain,  coming  on  several  hours  after  eating,  might  equally  well  be 
ascribed  to  hyperacidity. 

Differential  Diagnosis 

It  will  be  seen  from  the  above  histories,  and  still  more  so  from 
the  autopsy  records  of  cases  of  this  class,  that  the  differential  diag- 
nosis is  often  very  diflicult,  especially  when  there  is  neither  hsema- 
temesis  nor  melsena.  In  such  cases  many  physicians  prefer  not  to 
commit  themselves  to  a  diagnosis  or  to  attempt  a  differential  diag- 
nosis. I  think  this  is  going  too  far.  If  we  were  to  wait  for  the 
appearance  of  hemorrhage  in  gastric  ulcer,  at  least  30  per  cent  of  all 
the  cases  would  remain  undiagnosticated,  and  therefore  uncured. 

In  my  opinion  the  greatest  difiiculty  lies  in  distinguishing  ulcer 
of  the  duodenum  from  gastric  hyperacidity.     Yery  often  both  dis- 


290  DISEASES  OF   THE  INTESTINES 

eases  give  the  same  symptoms :  pain  several  liours  after  eating, 
relieved  by  the  ingestion  of  food  or  alkalies,  and  localized  at  the 
pylorus  or  in  the  duodenum.  The  23ylorus  and  duodenal  region 
may  be  more  or  less  sensitive  to  pressure  in  hyperacidity.  I  think 
that  when  the  latter  cases  do  not  imj)rove  uj)on  a  diet  suitable  to 
that  condition,  it  would  be  well  to  begin  treatment  as  for  ulcer  as 
soon  as  possible.  I  have  done  so  several  times,  with  the  result  that 
from  that  time  on  the  patients  were  free  from  their  discomforts. 
Just  as  in  gastric  ulcer,  von  Leube's  treatment  has  a  certain  value 
for  the  differential  diagnosis  of  doubtful  cases,  so,  in  long-estab- 
lished cases  of  hyperacidity  with  symptoms  suggestive  of  ulcer  of 
the  duodenum  I  would  recommend  that  the  treatment  for  the  latter 
condition  should  be  instituted  experimentally. 

As  in  gastric  ulcer,  the  differential  diagnosis  between  duode- 
nal ulcer  and  irregular  cholelithiasis,  with  or  without  icterus  or 
cholangitis,  may  be  exceedingly  difficult.  Icterus  as  well  as  intes- 
tinal hemorrhage  are  not  uncommon  in  cholelithiasis.  In  his  Clin- 
ical Study  of  Cholelithiasis  (p.  130  et  seq.),  to  which  we  refer  the 
reader  for  further  information,  Naunyn  has  described  the  various 
conditions  in  which  the  latter  ajffection  may  be  associated  with  intes- 
tinal hemorrhage.  From  a  differential  diagnostic  standpoint  the 
following  must  be  noted :  enlargement,  tenderness,  and  tumefac- 
tion of  the  liver,  the  presence  of  a  decided  sensitiveness  on  pressure 
over  the  posterior  surface  of  the  liver  (in  the  neighbourhood  of  the 
twelfth  dorsal  vertebra),  and  sometimes  an  intermittent  pyrexia.  In 
complicated  cases  it  is  difficult  to  avoid  mistakes. 

If  the  pains  are  atypical  with  frequent  remissions  and  exacerba- 
tions, a  correct  diagnosis  is  merely  a  matter  of  accident.  As  an 
illustration  of  this  I  will  give  one  of  the  numerous  mistaken  diag- 
noses which  appear  in  clinical  records — that  pubHshed  by  Had- 
ham^.  A  painter  suffered  from  severe  colicky  pains  with  free 
vomiting,  which,  as  his  gums  showed  the  lead  line,  were  taken  to 
indicate  lead  colic.  Autopsy  revealed  an  ulcer  with  sharp  cut  mar- 
gins on  the  anterior  wall  of  the  duodenum.  Two  similar  obser- 
vations have  recently  been  reported  by  Alvazzi-Delfrate^*. 

When  there  are  intestinal  hemorrhages,  the  chances  for  a  cor- 
rect diagnosis  are  more  favourable.'  The  hemorrhage  in  itself  is, 
however,  not  pathognomonic.  The  diagnosis  can  only  be  safely 
made  when  all  the  chnical  symptoms  are  present,  but  even  then 
it  is  often  exceedingly  difficult  to  distinguish  duodenal  from  gas- 
tric ulcer.      If  we  arrange  the  differential  features  in  the  order 


EOUND   ULCER  OF  THE   DUODENUM  291 

of  their  value,  age  and  sex  must  be  given  first  importance.  Ulcer 
of  the  duodenum  occurs  with  preponderating  frequency  during 
the  third  and  fourth  decades,  ulcer  of  the  stomach  during  the 
developmental  age ;  ulcer  of  the  duodenum  is  vastly  more  frequent 
in  men  than  in  women.  In  duodenal  ulcer  there  is  an  absence  of 
special  gastric  symptoms,  such  as  anorexia  and  vomiting ;  ingestion 
of  food  does  not  increase  the  pain,  but  diminishes  it  if  present ; 
the  pain  is  localized  and  does  not  radiate ;  hemorrhage  per  os  when 
present  at  all,  is  scanty  in  comparison  with  the  melsena ;  the  hemor- 
rhages are  repeated  extremely  often,  while  in  gastric  ulcer  they  are 
not  so  common. 

Although  the  treatment  of  both  kinds  of  nlcers  and  the  thera- 
peutic results  obtained  are  the  same,  an  attempt  should  be  made  to 
distinguish  between  the  two  conditions,  if  possible,  for,  aside  from 
the  danger  of  perforation,  the  prognosis  of  duodenal  ulcer  is 
much  more  favourable  than  that  of  gastric  ulcer,  since  the  tend- 
ency to  stenosis  or  carcinomatous  formation  (see  p.  293)  is  mark- 
edly less. 

Complications 

Duodenal  ulcer  is  noted  for  the  remarkable  number  of  its  com- 
plications. Either  because  of  their  frequency  or  on  account  of 
the  peculiar  symptoms  to  which  they  give  rise,  some  of  these  are  of 
practical  importance.     The  most  important  is  : 

1.  Perforative  Peritonitis. — In  Collin's  collection  of  262  cases 
this  was  observed  181  times,  or  69  per  cent.  The  seat  of  the  perfo- 
ration— and  this  is  of  especial  importance  to  the  surgeon — like 
that  of  gastric  ulcer,  is  usually  on  the  anterior  wall.  The  rupture 
may  occur  into  the  abdominal  cavity  and  thus  cause  death  by  per- 
forative peritonitis,*  or  else  neighbouring  organs — the  liver,  the 
pancreas,  the  gall  bladder,  or  colon — may  be  encroached  upon.  In 
this  way  permanent  adhesions  or  fistulous  openings  into  the  gall 
bladder  or  the  colon  are  formed,  or  there  may  be  an  erosion  of 
an  important  artery  or  vein  and  death  from  hemorrhage,  or  a  sub- 
phrenic abscess  with  pyopneumothorax,  may  result. 

Furthermore,  a  duodenal  ulcer  on  the  anterior  or  posterior  wall 
may  cause  an  abscess,  and  ultimately,  by  perforation  of  the  abdomi- 
nal wall,  result  in  a  duodenal  fistula ;   or  the   ulcer   may  rupture 

*  As  has  been  shown  by  a  case  reported  by  Bardeleben  (Virehow's  Archiv, 
vol.  V,  p.  2),  the  perforation  need  not  always  cause  peritonitis.  The  fatal  result 
may  come  about  just  as  rapidly  from  shock,  collapse,  or  hemorrhage. 


292  DISEASES   OP  THE  INTESTINES 

into  a  cavitj  walled  off  bv  previous  adhesions,  which,  increase  until 
the  abscess  is  so  encapsulated  as  to  produce  a  plastic  resisting  mass. 
I  have  seen  a  case  which  I  believe  to  have  been  of  this  sort. 

All  these  possibihties  are  founded  upon  more  or  less  numerous 
chnical  observations  described  in  the  above-mentioned  monographs 
on  duodenal  ulcer.  Since  it  would  take  too  long  to  describe  each 
of  them,  the  reader  is  referred  to  these  authors  for  details.  There 
are  no  specific  sjmjDtoms  which  indicate  the  site  of  the  perfo- 
ration. The  answer  is  most  decidedly  in  the  negative.  There 
are  accounts  of  operations  (Bryant^,  Brissaud ^®,  Sheild^,  Lock- 
wood^,  Lennander^)  undertaken  for  supposed  perforating  appen- 
dicitis, in  which  the  autopsies  showed  that  the  cause  lay  in  a 
duodenal  ulcer  that  had  perforated.  The  error  was  usually  due  to 
the  fact  that  the  chief  painful  point  was  located  in  the  ileo-csecal 
region.  It  is  hardly  necessary  to  call  special  attention  to  the  cir- 
cumstance that  a  diagnosis  of  perforation  is  open  to  all  the  mistakes 
that  may  be  made  in  the  diagnosis  of  perforation  of  an  ulcer  in 
any  other  part  of  the  intestine  (strangulation,  etc.). 

2.  löterus. — Icterus  is  occasionally  observed  as  a  complication 
of  duodenal  ulcer,  although  Collin  could  collect  only  9  cases  in 
which  it  occurred.  It  begins  as  a  true  duodenitis,  which  involves 
the  papilla  of  Yater.  Cases  of  this  kind  have  been  seen  by  so 
competent  an  observer  as  Henoch,  so  that  there  is  no  good  rea- 
son for  doubting  them.  The  jaundice  has  the  well-known  char- 
acter of  the  catarrhal  form,  except  that  it  is  transient  and  does 
not  cause  enlargement  of  the  liver.  In  a  case  reported  by  Krauss, 
the  cause  of  the  icterus  was  inflammatory  adhesion  of  the  duode- 
num to  the  gall  bladder.  Another  form,  moi-e  easily  accounted 
for  by  what  will  shortly  be  described,  occurs  when  the  ulcer  is  located 
in  the  descending  portion  of  the  duodenum. 

On  account  of  its  infrequency,  icterus  is  of  scarcely  any  impor- 
tance for  diagnostic  or  differential  diagnostic  purposes.  Except 
under  some  favourable  circumstances,  it  rarely  throws  any  light 
upon  the  clinical  picture. 

3.  Formation,  of  Stenoses  hy  Cicatrization  of  the  Ulcer. — In  a 
small  number  of  cases  the  cicatrization  of  a  duodenal  ulcer  leads  to 
stenosis  and  consecutive  dilatation  of  the  parts  lying  above  it — that 
is,  of  the  stomach,  or  the  corresponding  portion  of  the  duodenum. 
As  the  ulcer  is  most  frequently  in  that  part  of  the  duodenum  adja- 
cent to  the  stomach,  it  is  in  the  latter  organ  that  ectasia  is  most 
often  met  with  ;  according  to  Collin,  18  times  in  262  cases.     Duo- 


ROUND  ULCER  OF  THE  DUODENUM  293 

denal  dilatation  was  observed  only  4  times.  The  symptoms  of  this 
condition  will  be  considered  in  the  chapter  on  Intestinal  Stenosis. 
Lastly,  in  rare  cases,  when  the  ulcer  is  located  in  the  neighbour- 
hood of  the  amjmlla  of  Yater,  obliteration  of  the  common  bile 
duct  and  permanent  jaundice  may  follow.  This  complication  will 
make  the  diagnosis  and  the  treatment  veiy  difficult. 

4.  Carcinomatous  Ulcer  of  the  Duodenum,. — Carcinomatous  de- 
generation of  the  ulcer  seems  to  be  rare.  Altogether,  but  4  cases 
have  been  observed  (Eichhorst ^^,  Ewald ^^,  Mackenzie^,  Schrötter^'). 
Unless  it  be  that  many  cases  are  overlooked,  this  would  constitute  a 
striking  variance  from  the  frequency  of  carcinomatous  ulcer  of  the 
stomach. 

Treatment 

The  treatment  of  ulcer  of  the  duodenum  differs  only  in  a  few 
points  from  that  of  ulcer  of  the  stomach.  For  the  details  of  the 
latter  I  would  refer  to  my  Diagnosis  and  Treatment  of  Diseases  of 
the  Stomach,  Part  II,  third  edition,  page  55,  and  will  limit  what 
follows  to  a  brief  sketch  of  the  plan  of  treatment. 

If  hemorrhage  set  in,  absolute  rest  in  bed  is  the  first  require- 
ment. The  stomach  should  be  put  at  rest,  and  for  several  days  ali- 
mentation carried  on  by  the  rectum.  Following  this,  the  most  prom  - 
ising  course  is  von  Leube's  rest-cure  treatment  for  ten  to  fourteen 
days,  with  the  application  of  warm  poultices,  and  a  milk  diet.  After 
the  cessation  of  the  pain  the  diet  may  be  cautiously  increased  week 
by  week.  Alkalies  or  Carlsbad  water,  bismuth  or  nitrate  of  silver, 
may  be  useful  as  adjuvants.  In  very  obstinate  cases  it  is  advisable 
to  give  the  stomach  a  rest  by  exclusive  rectal  feeding,  under  careful 
supervision,  for  a  week  or  a  fortnight.  Opiates  can  not  be  dis- 
pensed with  when  the  pain  is  severe.  Long-continued  physical 
rest,  careful  diet,  and  the  avoidance  of  alcohol  and  tobacco  are  to  be 
insisted  upon. 

When  a  cure  is  not  obtained  by  palliative  measures,  and  life 
is  threatened  by  continuous  pain  or  profuse  hemorrhages,  when 
there  are  symptoms  of  cicatricial  stenoses  not  relieved  by  lavage, 
or  when  there  is  perforative  peritonitis  or  subphrenic  abscess,  sur- 
gical procedures  may  be  indicated.  Owing  to  the  analogy  which 
these  indications  bear  to  those  that  arise  in  ulcer  of  the  stomach, 
we  refer  the  reader  to  the  latest  work  of  Mikulicz  ^^. 

Up  to  the  present  time  experience  in  the  surgery  of  duodenal 
ulcer  has  been  scanty.  In  one  case  Codivilla^  excised  the  ulcer 
20 


294  DISEASES  OF  THE  INTESTINES 

by  a  gastro-enterotomv  with  good  result.  Lange  ^  performed  a 
plastic  operation  on  the  pylorus  in  a  ease  of  cicatricial  stenosis  from 
duodenal  ulcer,  with  equally  good  result. 

Operations  for  perforative  peritonitis  have  been  successfully 
performed  in  several  quarters  (Herczl^,  Landerer  and  Glücks- 
mann ^^,  Wannach  ^''^ ).  In  three  cases  reported  by  Lennander^  a 
fatal  termination  occurred  in  spite  of  the  operation. 

In  view  of  the  absolutely  hopeless  prognosis  of  ulcer  of  the 
duodenum  after  perforation,  surgical  intervention  should  be  un- 
dertaken as  soon  as  possible — within  ten  to  twelve  hours  at  least 
after  the  diagnosis  is  assured  and  the  primary  shock  has  been  recov- 
ered from. 

Subphrenic  pyopneumothorax  or  other  abscess  formations,  are 
treated  according  to  the  prevailing  surgical  methods. 

LITERATURE 

1.  J.  Krauss.     Das  perforirende  Geschwür  im  Duodenum,  Berlin,  1865. 

2.  Chvostek.     Medicinische  Jahrbücher,  Wien,  1883,  Heft  1,  S.  1-58. 

3.  Boucquoy.     Archives  generales  de  medecine,  1887. 

4.  Oppenheimer.     Das  Ulcus  pepticum  duodenale.      Inaug. -Dissert.,   Würz- 

burg, 1891. 

5.  Beckmann,     üeber  Ulcus  duodenale  u.  seine  Diagnose.      Inaug-Dissert., 

Berlin,  1893. 

6.  Collin.     Etude  sur  I'ulcere  simple  du  duodenum.     These  de  Paris,  1894. 

7.  Dickenson.     Royal  Med.  and  Chirurg.  Society,  January  9,  1894. 

8.  Perry  and  Shaw.     Guy's  Hosp.  Rep.,  p.  171,  1894. 

9.  Marmaduke  Sheild.     Internat.  Med.  Magazine,  vol.  iii,  No.  12,  1895. 

10.  Schulze.     Beiträge  z.    Kenntniss  des    perforirenden  Duodenalgeschwürs. 

Inaug. -Dissert.,  Greifswald,  1873. 

11.  Brambillo.     Cited  from  Virchow-Hirsch's  Jahresber.,  1882,  Bd.  ii,  S.  168. 

12.  Pauly.     Aerztliche  Sachverständigen  Zeitung,  1897. 

13.  L.  Landau.     Ueber  Meläna.   der  Neugeborenen  u.  Bemerkungen   über  d. 

Obliteration  d.  fötalen  Wege.     Breslau,  1874. 

14.  V.  Mering.     Verhandl.  d.  Congresses  f.  innere  Medicin,  1893. 

15.  Moritz.      Verhandl.   d.   65  Versammlung  d.   Gesellsch.  deutscher  Natur- 

forsche u.  Aerzte  in  Nürnberg,  1893. 

16.  Burwinkel.     Deutsche  med.  Wochenschr.,  1898,  No.  52. 

17.  Albers.     Die  Darmgeschwüre,  1831. 

18.  Mayer.     Die  Krankheiten  des  Zwölffingerdarmes,  Düsseldorf,  1844. 

19.  Stärke.     Deutsche  Klinik,  1870. 

20.  V.  Leube.     Specielle  Diagnose,  2te  Aufl.,  S.  274. 

21.  A.  Robin.     Cited  frorn  Collin  (reference  No.  6). 

22.  Devic  and  Roux.     Province  medicale,  44^7,  1895. 

23.  Hadham.     The  Lancet,  February  18,  1871. 


ROUND  ULCER  OF  THE  DUODENUM  295 

24.  Alvazzi-D  elf  rate.     Gaz.  med.   di  Torino,   1897,  No.   7.     Cited  from  Cen- 

tralbl.  f.  innere  Medicin,  1897,  S.  845. 
35.  Bryant.     Semaine  medicale,  1893,  p.   335.     Cited  from  Collin  (reference 

No.  6). 

26.  Lockwood.     Transact.  Med.  Soc,  vol.  xv,  p.  91,  1895.     Cited  from  review 

in  Centralbl.  f.  Chirurgie,  1895,  No.  26. 

27.  Lennander.     Ueber  Appendicitis,  1895,  S.  29. 

28.  Eichhorst.     Schmidt's  Jahrbücher,  Bd.  ccxx,  S.  23. 

29.  C.  A.  Ewald.     Berliner  klin.  Wochenschr.,  1886,  No.  32. 

30.  Mackenzie.     St.  Thomas  Hosp.  Rep.,  vol.  xx,  p.  341,  1892. 

31.  Schrötter.     Aerztliche  Bericht  des  k.  k.  Allgem.  Krankenhauses  zu  Wien, 

1887,  S.  27. 

32.  Mikulicz.     Mittheilungen  a.  d.  Grenzgeb.  d.  Medicin  \i.  Chirurgie,   1897, 

Bd.  ii. 

33.  Codi  villa.     Sperimentale,  Mem.  orig.,  vol.  xlvii,  pp.  4  and  6.      Cited  from 

Landerer  u.  Glücksmann  (reference  No.   36). 

34.  Lange.     Annals  of  Surgery,  vol.  xxxvi,  p.  2,  1893. 

35.  Herczl.     Orvosi  Hetilap,    1895,   No.   50.      Cited  from  Arch.   f.    Verdau- 

ungskr.,  Bd.  ii,  S.  251. 

36.  Landerer  u.    Glücksmann.      Mittheilungen  a.   d.   Grenzgeb.  d.   Med.    u, 

Chirurgie,  1896,  Bd.  i,  S.  168. 

37.  Wannach.     Arch.  f.  klin.  Chirurgie,  1898,  Bd.  Ivi,  Heft  2. 

38.  Lennander.     Mittheilungen  a.  d.  Grenzgeb.  d.   Med.  u,  Chirurgie,  1898, 

Bd.  iv,  Heft  1,  S.  91. 


CHAPTEE  Xyil 

INTESTINAL  NEOPLASMS 

A.    MALIGNANT  NEOPLASMS  OF  THE  INTESTINES 

I.    Carcinoma 

Preliminary  Remarks. — Malignant  tumours  of  the  intestines 
are  so  very  frequently  carcinomatous  that,  in  discussions  relating  to 
malignant  new  growths,  cancer  is  almost  exclusively  the  tumour  in 
question.  The  other  malignant  tumours  (sarcoma,  lymphosarcoma), 
however,  will  require  brief  consideration  because  of  the  well-marked 
cHnical  pictures  they  occasionally  present. 

Regarding  the  absolute  and  relative  frequency  of  intestinal  car- 
cinoma, there  are  many  extensive  and  instructive  statistics. 

A.  Zemann^  found,  in  21,624  autopsies  performed  at  the  Vienna 
General  Hospital,  2,070  neoplasms  directly  causing  death,  of  which 
number  1,744  were  cancers — ^i.  e.,  84  per  cent  of  all  neoplasms. 

Of  these  1,744  cancer  cases,  912  (52  per  cent)  were  tumours  of 
the  gastro-intestinal  canal,  the  "  canal "  in  this  sense  beginning  at 
the  tongue  and  including  the  anal  orifice. 

The  various  portions  of  the  gastro-intestinal  tract  were  affected 
in  the  following  proportion  : 

Tongue 37 

Pharynx 34 

(Esophagus 136 

Stomach 540* 

Duodenum 3 

Ileum 6 

Caecum 12 

Vermiform  appendix 1   \-  165 

Colon 32 

Sigmoid  flexure 30 

Rectum 81 

*  I.  e.,  2.5  per  cent  of  all  the  autopsies. 
296 


INTESTINAL  NEOPLASMS  29Y 

In  his  excellent  work  on  the  intestines,  ISTothnagel  tabulates  like 
statistics  derived  from  a  study  of  similar  material.  George  Hei- 
mann^  has  recently  published  extensive  tables  which  are  very  useful 
in  the  study  of  the  pathology  of  the  alimentary  canal.  During  the 
years  1895  and  1896,  20,054  patients  died  of  cancer  in  the  gen- 
eral hospitals  of  Prussia,  of  whom  10,537  were  cases  of  cancer  of 
the  gastro-intestinal  tract.  The  different  portions  of  the  canal  were 
affected  as  follows : 

Tongue 269 

Pharyngeal  and  buccal  mucous  membrane . .  192 

(Esophagus 1,011 

Stomach 4,288 

Intestinal  canal  in  toto 1,706 

Of  these,  the  rectum 1,204 

Liver  and  gall  bladder 979 

Pancreas 92 

Of  the  cases  of  cancer  of  the  intestines  (exclusive  of  the  rectum), 
20  involved  the  small  intestine  and  224  the  large  intestine ;  49  of 
the  latter  affected  the  sigmoid  flexure  ;  in  258  cases  the  portion  af- 
fected was  not  mentioned. 

These  statistics  (which  in  the  main  agree  with  others)  demon- 
strate the  relative  infrequency  of  intestinal  cancer  as  compared 
with  cancer  of  the  stomach.  The  striking  disparity  in  numbers 
between  cancer  of  the  small  and  that  of  the  large  intestine,  and 
the  overwhelming  frequency  of  rectal  cancer,  are  noteworthy. 
Finally,  these  statistics  prove  the  frequency  of  cancer  of  the  sig- 
moid flexure,  l^ext  in  frequency  to  these  are  the  carcinomata  of 
the  colon  (especially  at  the  flexures),  and  last  of  all  those  of  the 
caecum. 

Eegarding  sex,  authorities  differ.  Some  believe  that  females 
are  of tener  affected  (Berard  ^,  Kokitansky  ^,  P.  Kiipp  *)  while  others 
regard  intestinal  cancer  as  more  frequent  in  males  (MaydP,  G. 
Heimann  '^).  It  is  certain,  however,  that  cancer  of  the  rectum  occurs 
more  frequently  in  men. 

The  age  of  the  patient  is  an  important  consideration.  Most  cases 
occur  between  the  fourth  and  sixth  decades.  As  Maydl  ^  I^othnagel, 
and  G.  Heimann  ^  correctly  pointed  out,  intestinal  cancer  quite  fre- 
quently occurs  in  even  the  earlier  periods  of  life  ;  particularly  is  this 
true  of  cancer  of  the  rectum,  many  cases  of  which  have  been  ob- 
served in  young  people.    In  partial  contrast  to  the  above,  sarcoma  and 


298  DISEASES  OF  THE  INTEST^ES 

lymphosarcoma  occur  usuallj  during  the  first  to  the  fourth  decades, 
and  only  very  infrequently  in  the  fifth  and  sixth.  Regarding  fre- 
quency^ sarcoma,  in  contrast  to  carcinoma,  is  oftener  situated  in  the 
small  intestine  than  in  the  large.     (Compare  chapter  on  Sarcoma.) 

It  will  hardly  be  necessary  to  discuss  at  length  the  etiology  of 
cancer  and  sarcoma,  since,  with  the  exception  of  the  bacterial  and 
protozoan  theories,  nothing  of  importance  has  been  brought  to  light. 
On  the  other  hand,  histological  investigations  by  modern  investi- 
gators, particularly  Yirchow,  Thiersch,  Waldeyer,  Häuser,*  ßib- 
bert,  Hansemann,  Lubarsch,  and  others,  have  proved  more  fruit- 
ful. A  full  description  of  these  as  yet  incomplete  investigations 
would  lead  too  far,  hence  we  will  mention  only  a  few  pertinent 
facts.  In  the  great  majority  of  cases  intestinal  cancer  is  a  primary 
affection,  very  rarely  metastatic.  The  most  frequent  form  is  cylin- 
drical epithelial.  It  originates,  as  do  all  other  forms  of  intestinal 
cancer,  from  the  cylindrical  epithelial  cells,  and  shows  most  often  a 
glandular  type  (hence  "  carcinoma  adenomatosum  cylindro-epitheli- 
ale,"  Häuser,  loc.  cit.).  The  second  most  frequent  form  is  the 
medullary  (carcinoma  medulläre),  which  shows  a  decided  tendency 
to  break  down  and  form  ulcerations  (intestinal  hemorrhages).  Some- 
what less  frequent  (most  often  in  the  rectum)  is  colloid  carcinoma. 
In  striking  contrast  to  the  stomach,  true  scirrhous  cancer  occurs 
very  rarely  in  the  intestine,  in  most  cases  in  the  rectum. 

The  histological  construction  of  the  different  types  is  not  with- 
out its  clinical  significance.  The  soft,  medullary  type  of  cancer 
generally  forms  a  diffuse  tumour,  while  the  scirrhous  is  a  different 
growth,  infiltrating  the  intestinal  walls  and  being  occasionally  quite 
circumscribed.    There  are,  however,  exceptions  to  both  these  forms. 

In  its  early  stages  cancer  of  the  large  intestine  produces  but 
slight  changes  in  the  mucous  membrane  ;  only  later  does  the  growth 
show  its  special  characteristics — propagation  and  tendency  to  ulcera- 
tion. Another  characteristic  is  its  growth  in  a  circular,  girdlelike 
fashion.  Isolated  nodules  (at  times  of  large  size),  or  long,  diffuse 
infiltration,  rarely  occur. 

From  the  two  above-mentioned  characteristics  (viz.,  tendency 
to  ulceration  and  circular  growth  of  the  tumour)  we  have  the 
following  two  clinical  conditions  :   A  tendency  to  hemorrhage  to 


*  Compare  Hauser's  interesting  and  critical  description  of  the  diiferent  theories 
of  cancer  in  Das  Cylinderepithel  Careinom  des  Magens  und  Dickdarms,  Jena, 
1890,  p.  109. 


INTESTINAL  NEOPLASMS  299 

purulent  disintegration,  even  to  separation  of  portions  of  the  tumour 
and  the  development  of  stenoses.  These  symptoms  will  later  be 
discussed  at  length. 

Because  of  this  tendency  to  ulcerate,  superficial  layers  of  the 
bowel  may  be  involved  in  this  destructive  process,  and  perfora- 
tion may  occur.  The  development  of  a  stenosis,  which  may  at 
times  cause  complete  obstruction,  produces  dilatation  and  muscu- 
lar hypertrophy  of  that  portion  of  the  intestine  above  the  stricture. 
Through  overaction  in  this  dilated  and  hypertrophied  portion  nor- 
mal propulsion  of  contents  is  maintained,  until  a  disproportion 
between  the  power  of  the  hypertrophied  wall  and  the  resistance 
offered  occurs,  and  an  intestinal  paralysis  (ileus  paralyticus),  or, 
from  extreme  overexertion  of  the  hypertrophied  part,  a  rupture 
of  the  intestine  at  its  weakest  point  results. 

The  peculiar  characteristic  of  cancer  to  form  metastases  by  way 
of  the  blood  and  lymph  channels  is  also  present  in  intestinal  car- 
cinoma. 

The  mesentery  is  supplied  with  lymphatics  which  lead  to  the 
mesenteric  glands,  and  hence  the  latter  are  the  first  to  become 
diseased,  further  metastatic  involvement  depending  upon  the  site 
of  the  tumour.  Thus,  according  to  Riipp  ^,  the  lumbar  glands  are 
involved  in  cancer  of  the  sigmoid  flexure  of  the  colon  ;  the  omental, 
and  later  the  prevertebral  glands,  in  cancer  of  the  transverse  colon. 

Metastatic  carcinoma  of  the  lymph  nodes  may  cause  secondary 
intestinal  obstruction,  a  condition  which  I  have  twice  observed  in 
cancer  of  the  uterus.  Disseminated  carcinosis  of  the  peritoneum  is 
relatively  frequent. 

The  observations  of  MaydP  and  Hausmann ''^,  confirmed  by 
Rüpp  ^,  are  of  extreme  surgical  interest.  They  assert  that  metas- 
tases are  observed  only  late  in  intestinal  carcinoma ;  this  is  partic- 
ularly true  of  cancer  of  the  rectum.  Iverson  ^  cites  47  autop- 
sies of  rectal  carcinoma,  of  which  21  were  free  from  secondary 
involvement  of  glandular  organs;  Kraske®,  in  12  cases,  found 
metastases  in  only  6. 

According  to  Häuser  (loc.  cit.),  there  is  a  connection  between  the 
type  of  carcinoma  and  location  and  variety  of  the  metastatic  for- 
mations. Thus  colloid  carcinoma  very  rarely  causes  secondary 
involvement  of  internal  organs  (e.  g.,  the  liver),  but  frequently 
secondarily  involves  the  serosa,  lymph  glands,  and  bones.  Large 
medullary  carcinoma  produces  metastases  principally  in  the  re- 
gional lymph  glands,  while  the  small  scirrhus  may  cause  a  large 


300  DISEASES   OF   THE  INTESTINES 

metastatic  deposit  in  the  liver.  Besides  the  lymph  channels,  cancer 
may  also  spread  by  way  of  the  blood-vessels.  Tumour  masses  may 
erode  the  vascular  wall  (particularly  of  the  veins),  and  thus  infec- 
tious material  enters  the  blood  stream.  Since  its  tributaries  are 
directly  in  the  intestines  and  are  often  connected  with  the  ma- 
lignant growth,  the  portal  vein  is  especially  prone  to  carry  infec- 
tion, For  this  reason  the  liver  is  often  secondaiily  involved,  while 
metastatic  deposits  in  the  lungs,  uterus,  and  ovaries  are  rarer. 

The  tumour  frequently  becomes  adherent  to  the  neighbouring 
organs.  Such  adhesions  may  lead  to  complications,  but  they  are 
favourable  in  so  far  as  they  prevent  perforation.  The  most  fre- 
quent complications  of  this  kind  are  adhesions  to  and  fistulous  com- 
munication with  the  stomach,  bladder,  other  portions  of  the  intes- 
tines, the  abdominal  wall,  genitals,  etc. 

General  Symptomatology  and  Diagnosis  of  Intestinal 
Carcinoma 

The  symptoms  of  intestinal  cancer  vary  so  much  according  to 
its  location  that  it  seems  judicious  to  consider  separately  cancer  of 
the  small  intestines,  the  colon,  and  the  rectum.  A  description  of 
sarcomatous  and  lymphosarcomatous  diseases  of  the  intestines  will 
be  found  in  another  chapter. 

All  cancers  have  certain  general  characteristics,  which,  although 
of  no  special  significance  individually,  collectively  complete  the 
clinical  picture  of  the  disease.  These  are  the  history,  the  deport- 
ment of  the  body  weight,  the  condition  of  the  urine  and  blood,  the 
occurrence  of  oedema  of  the  ankles  or  of  ascites,  and,  finally,  the 
presence  of  infiltrated  lymph  glands. 

1.  Hereditary  disposition  to  carcinoma  is  perhaps  of  value. 
Many  striking  examples  of  such  a  tendency  have  been  described 
(e.  g.,  family  of  ISTapoleon  I).  Traumatisms  received  during  recent 
years  should  be  noted  in  the  history. 

2.  In  obscure  or  atypical  cases  of  intestinal  cancer  the  hody 
weight  is  of  great  importance,  but  is  frequently  not  sufliciently 
considered.  My  experience  has  taught  me  that  patients  weigh 
themselves  only  when  there  has  already  been  quite  an  apparent 
loss  of  weight,  perhaps  even  as  much  as  10  to  20  pounds.  At  this 
stage,  too,  there  is  beginning  cachexia.  By  weighing  the  patient 
at  regular  intervals  the  physician  niay  often  note  the  degenera- 
tive character  of  the  disease  much  earlier.  If  the  appetite  be 
good  and  the  condition  of  the  upper  portion  of  the  alimentary 


INTESTINAL  NEOPLASMS  301 

canal  normal,  forced  feeding  may  be  tried ;  if  the  patient  then 
lose  in  weight  there  is  probably  some  obscure  malignant  disease 
of  the  intestine,  nsuallj  a  neoplasm  present.  The  progressive  loss 
in  weight  should  neither  be  over-  nor  underestimated,  but  re- 
garded as  a  warning  to  examine  the  patient  with  greater  care  and 
frequency  in  order  to  recognise  the  obscure  condition  as  early  as 
possible.  It  must  be  remembered,  however,  that  increase  in  weight 
does  not  by  any  means  exclude  carcinoma. 

3.  The  examination  of  the  urine,  particularly  the  finding  of 
indican  and  of  Rosenbach's  colouring  matter  may  aid  in  making  a 
diagnosis.  The  diagnostic  significance  of  these  bodies  has  already 
been  dwelt  upon  (see  page  132).  Kast  and  Baas^^  attribute  special 
value  to  the  presence  of  ethereal  sulphuric  acids  in  the  urine  as  a 
sign  of  intestinal  putrefaction.  This  has  occasionally  been  impor- 
tant to  surgeons  in  determining  whether  a  stenotic  obstruction  was 
successfully  removed  by  operation  or  not.  Eommeläre  ^^  and  others 
drew  attention  to  a  lessened  excretion  of  nitrogen  by  the  urine  in 
carcinoma,  but  the  investigations  of  F.  Müller  ^^  and  G.  Klem- 
perer  ^^  have  shown  this  conclusion  to  be  deceptive. 

4.  Examination  of  the  Hood  in  cancer  is  of  little  diagnostic 
value.  There  is  a  diminution  in  percentage  of  haemoglobin,  accom- 
panied by  a  corresponding  decrease  in  the  number  of  red  blood-cells, 
and  of  the  specific  gravity  of  the  blood.  "  Digestion  leucocytosis," 
recently  claimed  by  Schneyer^^  as  diagnostic  for  cancer  of  the 
stomach,  has  been  disproved  by  later  investigations.  As  yet  we 
have  no  reports  regarding  its  occurrence  in  intestinal  cancer. 

F.  Henry  ^^  has  lately  called  attention  to  the  differentiation  between 
cancer  of  the  stomach  and  pernicious  anaemia  by  means  of  a  count 
of  the  blood-cells.  He  has  pointed  out  that  in  cancer  the  number 
of  erythrocytes  is  never  less  than  1,500,000  per  cubic  millimetre, 
while  in  pernicious  anseraia  it  is  almost  invariably  below  1,000,000. 

5.  The  early  occurrence  and  disappearance  of  oedema  of  the 
ankles  might,  with  a  certain  amount  of  reserve,  be  accepted  as  a 
contributory  sign  to  the  diagnosis  of  a  malignant  disease.  I  can  not 
recall  ever  having  seen  it  in  any  of  my  cases  of  intestinal  cancer, 
and  can  find  no  mention  of  it  elsewhere  in  the  literature  of  the  sub- 
ject (cf.  Intestinal  Sarcoma,  p.  332).  Ascites  is,  of  course,  one  of 
the  most  frequent  accompanying  symptoms  of  advanced  cancer  of 
the  intestines.  Once,  during  an  operation  for  cancer  of  the  caecum, 
I  observed  slight  ascites,  which,  because  of  its  small  quantity,  it 
had  been  impossible  to  diagnosticate  before  operation. 


302  DISEASES  OF  THE  INTESTINES 

6.  Markedly  enlarged  inguinal  or  supraclavicular  glands  may- 
lend  support  to  tlie  diagnosis.  Swelling  of  the  latter  group  is 
very  rare,  while  enlargement  of  the  inguinal  glands,  though  fre- 
quent, occurs  under  most  varied  conditions.  At  all  events,  exci- 
sion and  histological  examination  may  aid  the  diagnosis. 

(a)  CANCER   OF   THE   SMALL  INTESTINE 

For  the  clinical  diagnosis  of  cancer  of  the  small  intestine  it  is 
best  to  distinguish  between  cancer  of  the  duodenum  and  that  of 
the  jejunum  and  ileum. 

1.   Cancer  of  the  Duodenum, 

According  to  their  relation  to  the  papilla  of  Yater,  these  tumours 
of  the  duodenum  are  conveniently  subdivided  into  suprapapillary, 
infrapapillary,  and  circumpapillary, 

(o)  Suprapapillary  Cancer 

The  symptoms  of  suprapapillary  cancer  are  not  well  defined,  and 
it  is  exceptional  to  arrive  at  even  a  probable  diagnosis.  Of  some 
value  are  the  subjective  symptomis  produced  by  the  marked  disturb- 
ance of  gastric  motility :  the  f eehng  of  the  tension  and  pressure  or 
pain  in  the  epigastric  region,  eructations,  nausea  and  vomiting,  loss 
of  appetite,  constipation,  oliguria,  marked  thirst,  and  a  decided 
feeling  of  illness  and  increased  debility,  sometimes  sufficient  to 
confine  the  patient  to  bed. 

Of  the  objective  symptoms^  the  earliest  is  the  ])resence  of  a 
tumour.  This  lies  in  the  right  hypochondrium,  is  hard  and 
uneven,  painful  on  pressure,  and  is  entirely  immovable  or  only 
slightly  movable. 

The  second  objective  symptom  is  the  presence  of  a  supraduode- 
nal dilatation,  which  naturally  leads  to  enlargement  of  the  stomach. 
Here  it  will  not  be  sufficient  to  diagnosticate  simply  anatomical 
dilatation  of  the  stomach,  but  by  repeated  examinations  of  the 
stomach  contents  we  must  seek  for  proof  of  stagnation.  As  a  re- 
cently published  case  of  Czygan^^  has  shown,  the  examination  of 
the  stomach  contents  for  the  presence  or  absence  of  hydrochloric 
acid,  for  lactic  and  other  organic  acids,  for  sarcinse  and  yeast, 
lactic-acid  bacilli,  ferments,  etc.,  may  be  of  aid  to  the  diag- 
nosis. In  the  above-mentioned  case,  besides  a  tumour  in  the  right 
hypochondrium  and  all  other  symptoms  of  cancer,  there  was 
found  (except  a  few  days  before  death)  normal  hydrochloric-acid 


INTESTINAL  NEOPLASMS  303 

secretion  in  the  dilated  stomach.  I  found  the  same  chemical  con- 
ditions in  a  case  which  I  had  under  observation,  and  which,  because 
of  the  absence  of  tumour,  was  diagnosticated  as  a  benign  pyloric 
stenosis.  Laparotomy  disclosed  a  tumour  of  the  first  portion  of  the 
duodenum  as  the  cause  of  the  stenosis. 

We  must,  however,  not  lay  too  much  stress  upon  the  results 
of  chemical  examinations,  since  hydrochloric  acid  is  often  present 
for  a  long  time  in  carcinoma  of  the  pylorus,  and,  owing  to  the 
stagnation  which  results  from  proximity  to  the  stomach,  may  be 
absent  and  lactic  present  in  duodenal  cancer. 

Czygan  ^^  mentions  another  point  of  possible  diagnostic  value : 
the  presence  of  splashing  sounds,  particularly  hetween  the  tumour 
and  the  free  border  of  the  ribs.  Upon  emptying  the  stomach 
these  sounds  disappeared,  but,  upon  filling  the  organ,  were  again 
observed,  especially  in  the  region  above  mentioned. 

If  an  immovable  or  slightly  movable  tumour  be  felt  in  the  right 
hypochondrium,  by  careful  consideration  of  the  above  criteria  we 
may  venture  upon  the  probable  diagnosis  of  duodenal  cancer,  or,  at 
any  rate,  arrive  at  the  differential  diagnosis  between  this  disease 
and  cancer  of  the  pylorus.  When  no  tumour  is  palpable,  one  can 
diagnosticate  the  gastrectasis,  and,  under  favourable  circumstances, 
the  pyloric  stenosis  also. 

iß)   IXFRAPAPILLAKY   CARCINOMA 

Subjectively,  infrapapillary  carcinoma  differs  but  little  from 
the  above-described  suprapapillary  type,  excepting  in  one  very 
marked  symptom,  viz.,  the  vomiting  of  bile.  When  this  occurs 
constantly  it  should  arouse  suspicion  of  an  infrapapillary  ste- 
nosis. 

Objectively.— We  again  have  an  immovable  tumour  situated 
in  the  right  hypochondrium,  more  or  less  distant  from  the  free 
margin  of  the  ribs,  and  painful  on  pressure.  In  addition  there 
is  the  bilious  vomiting,  from  which  Leichten  stern  ^'^  was  the  first 
to  estabhsh  the  diagnosis  of  carcinoma  of  the  descending  portion 
of  the  duodenum.*  Examination  of  the  gastric  contents  will  fre- 
quently show  the  permanent  presence  of  bile  even  before  vomiting 
occurs. 

As  a  result  of  the  stagnation  of  contents,  dilatation  of  the 
stomach  may  gradually  be   established,  but  because   of   frequent 

*  According  to  A.  Pie,  Chomel  is  said  to  have  recognised  and  interpreted,  as 
early  as  1853,  continued  bilious  vomiting. 


304  DISEASES  OF  THE  INTESTINES 

vomiting,  mild  stenosis,  and  early  lavage  of  the  stomach  may  be 
overlooked. 

At  present  it  is  impossible  to  state  whether  the  examination  of 
the  gastric  contents  is  of  diagnostic  or  only  contributory  value. 
In  an  exhaustive  study  of  a  case,  Herz  ^^  constantly  found  lactic  acid 
present  and  hydrochloric  absent  in  the  strongly  bilious  stomach  con- 
tents. The  diagnosis  of  carcinoma  of  the  stomach  was  made,  but  the 
constant  presence  of  biliary  matter  might  have  attracted  attention 
to  the  real  seat  of  the  lesion.  Moreover,  a  tumour  was  not  palpable. 
The  presence  of  the  tumour  will  not  always  verify  a  probable 
diagnosis.  Thus,  for  example,  Gerhardi^^,  Hagenbach  ^'',  Wilms  ^^, 
and  others  have  shown  that  it  is  absolutely  impossible  at  times 
to  differentiate  between  infrapapillary  carcinoma  and  tumours  of 
the  head  of  the  pancreas.  Diseases  of  the  gall  bladder — e.  g., 
adhesions  to  the  duodenum,  compression  by  retroperitoneal  glandu- 
lar tumours,  cicatricial  strands  following  peritonitis,  etc. — are  con- 
ditions too  complicated  for  differentiation.* 

In  isolated  cases  the  history  and  chnical  course  of  the  disease 
are  of  some  assistance.  Previous  melsena  or  haematemesis,  signs  of 
cholelithiasis  or  of  an  old  duodenal  ulcer,  glycosuria,  or  fatty  stools, 
may  favour  the  one  or  the  other  diagnosis.  Weecke^  has  pointed 
out  that  irritations  or  ulcerations  of  the  walls  of  the  common  bile 
duct  by  gallstones  may  produce  duodenal  cancer,  particularly  the 
form  next  considered. 

In  the  absence  of  tumour  the  diagnosis  becomes  quite  uncer- 
tain. In  such  cases  the  age  of  the  patient,  emaciation,  oedemse,  or 
ascites  may  point  to  the  correct  diagnosis,  although  the  absence 
of  severe  general  symptoms  and  the  slow  development  of  the  dis- 
ease may  lead  to  a  more  optimistic  conclusion.  Such  favourable 
conditions  are,  however,  rare. 

y.    ClRCUMPAPILLARY   CARCINOMA 

In  this  the  neoplasm  develops  in  the  neighbourhood  of  the 
papilla  of  Yater  and  compresses  the  bile  duct.  Whether  in  these 
cases  we  have  to  do  with  primary  carcinoma  of  the  papilla,  or, 
as  Pic^^  contends,  with  cancer  of  the  pancreas,  is  certainly  of  scien- 
tific interest;  from  a  clinical  (particularly  a  diagnostic)  standpoint 

*  A  case  from  Kussmaul's  clinic,  described  by  Cahn  in  1886,  was  diagnosticated 
as  duodenal  cancer  on  account  of  the  presence  of  a  palpable  tumour  and  continu- 
ous biliary  vomiting.  The  autopsy  showed  a  retroperitoneal  lymphosarcoma  com- 
pressing the  descending  portion  of  the  duodenum. 


INTESTINAL  NEOPLASMS  305 

this  distinction  is  almost  valueless.  As  discussion  on  this  point  is 
foreign  to  the  subject  at  issue,  it  will  not  be  further  considered, 
and  we  shall  at  once  proceed  to  the  symptomatology  of  papillary 
Carcinoma. 

Subjective  Symptoms, — These  are  of  secondary  importance,  viz., 
pain  in  the  region  of  the  stomach  or  liver,  noncharacteristic  but 
not  biliary  vomiting,  constipation  or  diarrhcBa,  loss  of  appetite,  and 
progressive  loss  of  strength.  One  or  all  of  these  symptoms  may  be 
present,  but  they  are  of  less  value  than  the  objective  symptoms. 

Objective  Symptoms. — The  main  and  most  apparent  symptom  is 
icterus.  Bard  and  Pic  ^  have  shown,  however,  that  icterus  may  be 
entirely  absent,  and  maintain  that  when  a  tumour  and  icterus  are 
present  the  carcinoma  generally  has  its  origin  in  the  pancreas.  On 
the  other  hand,  Lannois  and  Courmont^  have  published  several 
cases  of  undoubted  ampullary  cancer  with  icterus.  I  myself  have 
made  two  similar  observations.  According  to  my  experience,  the 
manner  of  development  of  the  icterus  is  extremely  important.  As 
in  catarrhal  icterus,  this  is  sudden,  and  usually  without  pain,  but 
as  Janicke  has  shown,  severe  attacks  similar  to  gallstone  colic  may 
exceptionally  occur,  obscuring  the  true  clinical  picture.  The  diflB- 
culty  of  diagnosis  is  also  illustrated  by  a  case  which  I  observed 
of  cholelithiasis  with  a  large  gallstone  in  the  common  bile  duct. 
The  stone  was  passed  without  any  pain,  and  the  whole  condition 
was  accompanied  only  by  chronic  icterus.  Unless  sudden  inter- 
current complications — e.  g.,  marked  cachexia,  hsematemesis,  me- 
Isena,  and  irregular  fever — indicate  the  correct  diagnosis,  it  vdll  be 
impossible,  therefore,  in  the  first  few  days  or  weeks  of  the  disease, 
to  make  a  differential  diagnosis  between  simple  icterus,  cholelithia- 
sis, and  beginning  carcinoma 

The  longer  icterus  continues,  the  more  resistant  is  it  to  the 
usual  methods  of  treatment,  and  the  sooner  the  general  condition  of 
the  patient  suffers,  the  more  probable  will  the  diagnosis  of  a  malig- 
nant neoplasm  become,  particularly  when  the  above-mentioned  symp- 
toms occur  in  middle-aged  patients.  In  two  cases  of  absolute  ano- 
rexia under  my  observation,  the  total  absence  of  response  to  cus- 
tomary therapeutic  measures  aided  the  diagnosis,  because  such  ex- 
treme obstinacy  is  not  found  in  either  duodenal  icterus  or  chole- 
lithiasis. We  also  meet  with  this  extreme  anorexia  in  hypertrophic 
cirrhosis  of  the  liver  (which  is  otherwise  sufficiently  distinguished 
from  circumpapillary  carcinoma),  and  especially  in  pancreatic  carci- 
noma, soon  to  be  described.     To  my  knowledge,  no  examination  of 


306  DISEASES   OF   THE  INTESTINES 

the  stomacli  contents  in  cases  of  circumpapillaiy  carcinoma  liave 
been  published.  In  one  of  my  cases,  despite  absolute  anorexia, 
there  was  no  disturbance  in  the  chemical  or  the  motor  functions 
of  the  stomach. 

In  circumpapillary  carcinoma  the  liver  is  usually  not  enlarged, 
and  the  gall  bladder  is  decreased  in  size.  A  tumour  is  rarely 
palpable,  but  when  present  it  is  too  deeply  situated  to  be  distinctly 
outlined,  l^aturally,  as  in  the  case  described  by  Kernig  ^,  the  pres- 
ence of  a  tumour  is  of  great  aid  to  the  diagnosis ;  it  may,  however, 
be  misleading,  for  it  may  simulate  primary  cancer  of  the  gall  blad- 
der or  liver.  If  icterus  be  absent,  even  in  the  presence  of  a 
tumour  the  diagnosis  will  be  extremely  difficult.  It  may  be 
very  difficult  to  differentiate  between  carcinoma  of  the  papilla 
and  of  the  pancreas.  Bard  and  Pic^  have  recently  published 
a  set  of  symptoms  which,  recognised  sufficiently  early,  is  said  to 
render  the  diagnosis  of  cancer  of  the  pancreas  as  easy  as  that 
of  cancer  of  the  stomach.  The  symptoms  are  well-marked, 
constantly  increasing  icterus,  with  enormous  dilatation  of  the 
gall  bladder,  rapid  emaciation  and  cachexia,  usually  accompanied 
by  subnormal  temperature  and  absence  of  appreciable  enlarge- 
ment of  the  liver.  For  excellent  reasons,  in  which  I  fully 
concur,  Oser^  has  behttled  the  significance  of  this  clinical  syn- 
drome. 

Only  the  presence  of  sugar  in  the  urine  (according  to  Mi- 
rallie  ^^  this  occurs  in  26  per  cent  of  all  carcinomata  of  the  pancreas) 
or  of  certain  intestinal  symptoms  (bloody  evacuations,  hsematem- 
esis,  diarrhoeas)  may  point  to  the  one  or  other  condition  in  ques- 
tion.    None  of  these  symptoms  are  absolutely  diagnostic. 

2.   Carcinoma  of  the  Jejumtm  and  Ileum 

On  account  of  its  rarity  and  because,  as  stated  by  Treves  ^,  it 
very  seldom  forms  a  palpable  tumour,  carcinoma  of  the  jejunum  and 
ileum  possesses  but  httle  diagnostic  interest.  Unlike  cancer  of  the 
duodenum,  tumours  of  this  portion  of  the  intestine  are  extremely 
movable.  This  characteristic  may  make  it  difficult  to  differentiate 
them  from  cancer  of  the  large  intestine,  the  difficulty  naturally  be- 
coming greater  the  nearer  the  tumour  is  to  the  colon.  As  soon  as 
stenotic  symptoms  appear,  however,  jejunal  carcinoma  may  be  diag- 
nosticated. Enterorrhagia,  when  present,  may  be  of  value  in  mak- 
ing the  diagnosis. 

The  subjective  symptoms  are  very  similar  to  those  of  duodenal 


INTESTINAL  NEOPLASMS  307 

carcinoma :  colicky  pains,  increasing   marasmus,  anorexia,  nausea, 
vomiting,  and  constipation  alone  or  alternating  with  diarrhcEa. 

(]))    CARCINOMA   OF   THE   LARGE   INTESTINE    (EXCLUSIVE   OF 

THE   RECTUM) 

Although  cancer  of  the  small  intestine,  on  account  of  its  infre- 
quency,  possesses  comparatively  little  clinical  importance  the  case  is 
entirely  different  with  cancer  of  the  large  intestine.  In  the  latter, 
not  only  is  there  a  question  of  diagnosis  per  se,  but  also  of  the  ear- 
liest possible  diagnosis,  so  that  a  radical  surgical  operation  may  be 
performed.  For  such  early  diagnosis  it  is  necessary  to  have  in 
mind  not  only  classical  cases,  but  also  atypical,  irregular  forms  of 
the  disease. 

1.  Typical  Cases  of  Carcinoma  of  the  Large  Intestine 

Symptomatology  and  Diagnosis 

Subjective  Symptoms. — The  most  important  are  intestinal  pain, 
vomiting,  and  disturbances  of  intestinal  function.  In  concur- 
rence with  Riipp,  we  distinguish  the  fixed  or  tumour  pain  from 
colic  or  other  similar  paroxysmal  pains.  In  general,  tumour  pains 
are  dull  and  localized;  in  some  instances,  however,  they  may 
radiate  toward  the  back  or  the  sides,  toward  the  thorax,  and,  if 
the  tumour  be  deeply  situated,  toward  the  legs.  When  not  pal- 
pable, the  site  of  the  tumour  cannot  be  determined  by  the  locali- 
zation of  the  pains. 

The  paroxysmal  pains  are  of  greater  importance.  Even  in 
typical  cases  their  situation,  nature,  intensity,  and  duration  are  ex- 
tremely variable.  According  to  my  experience,  the  situation  of  the 
pain  often  points  to  the  site  of  the  tumour ;  occasionally,  however, 
the  pain  radiates  toward  the  umbilicus  or  over  the  whole  abdomen. 
The  pain  is  colicky  in  character,  with  remissions  and  exacerbations ; 
it  is  slight  at  its  beginning,  becomes  exceedingly  severe  as  it  reaches 
its  acme,  but  soon  decreases,  to  reappear  after  a  longer  or  shorter 
interval.  In  one  of  my  cases  the  remissions  lasted  precisely  ten 
minutes,  so  that  the  patient,  watch  in  hand,  could  exactly  foretell 
the  next  attack.  In  other  cases  the  paroxysms  continue  much 
longer,  sometimes  lasting  for  hours,  with  short  remissions  induced 
by  eructations,  passing  of  flatus,  or  by  vomiting.  In  patients  with 
complete  stricture  the  pain  is  constant.  Symptoms  of  ileus  then  de- 
velop.    Rüpp  *  states  that  the  pain  is  increased  directly  before  def- 


308  DISEASES  OF  THE  INTESTINES 

ecation,  especially  in  stenosis  of  the  lower  colon  and  when  purges 
are  given. 

The  picture  is  different  in  cancer  of  the  lower  bowel — i.  e.,  from 
the  lower  portion  of  the  descending  colon  downward.  Tenesmus 
is  prominent  and  characteristic.  Since  this  constitutes  one  of  the 
main  symptoms  of  rectal  cancer,  further  discussion  will  be  deferred 
until  the  chapter  on  Carcinoma  of  the  Rectum. 

Constipation  and  vomiting  are  very  intimately  related  to  the 
paroxysms  of  pain.  Constipation  stands  in  direct  relation  to  the 
pain :  the  severer  the  pain  the  longer  the  duration  and  the  more 
obstinate  the  constipation.  After  a  satisfactory  evacuation  the  pain 
disappears ;  when  the  colon  is  refilled  with  faeces,  paroxysms  recur. 
If,  in  spite  of  fsecal  movements,  pain  persists,  we  may  be  positive 
that  the  evacuation  was  insufficient. 

In  the  first  stage  of  the  disease  we  sometimes  find  diarrhoea 
alternating  with  constipation,  so  that  diarrhoea  follows  after  several 
days'  constipation.  In  still  other  cases  constipation  is  entirely  ab- 
sent ;  from  the  very  beginning  diarrhoea  of  a  nature  later  to  be 
described  is  present. 

The  clinical  picture  of  disturbed  intestinal  function  is  com- 
pleted by  the  appearance  of  vomiting.  The  vomiting  varies  accord- 
ing to  the  degree  of  stenosis.  It  may  consist  of  mucus,  stom- 
ach contents,  or  of  feculent  or  faecal  masses.  The  different  types 
of  vomiting  demonstrate  the  amount  of  obstruction.  With  Rüpp, 
I  think  feculent  vomiting,  even  in  severe  intestinal  stenosis,  is 
the  exception.  I  am  inclined  to  believe  that  the  vomiting  of 
mucus  and  of  stomach  contents  is  reflex  in  character,  similar 
to  that  associated  with  impacted  stone,  cardialgias,  disease  of  the 
genitals,  etc. 

In  one  of  my  cases  of  increasing  symptoms  of  stenosis,  haematem- 
esis  occurred  directly  before  the  operation.  The  patient  fortunately 
■withstood  the  shock  of  the  hemorrhage.  This  is  an  extremely  rare 
complication. 

Leaving  the  last-mentioned  symptom  (hsematemesis)  out  of  con- 
sideration, there  are  three  cardinal  diagnostic  symptoms,  viz.,  ob- 
stinate constipation  or  constipation  followed  by  diarrhoea,  colicky 
paroxysms,  and  vomiting.  Increasing  experience  has  shown  me 
that,  even  mthout  the  presence  of  a  j^alpable  tumour,  these  three 
symptoms  frequently  denote  intestinal  cancer.  The  frequency  of 
the  attacks,  the  characteristic  increase  of  the  paroxysmal  pain, 
increasing  constipation,  the  presence  of  unmistakable  cachexia  even 


INTESTINAL  NEOPLASMS  309 

in  this  stage,  and  marked  loss  of  body  weight,  all  point  toward 
the  correct  diagnosis. 

The  condition  of  the  remainder  of  the  alimentary  canal,  particu- 
larly of  the  stomach,  is  of  secondary  importance.  In  discussing  the 
objective  symptoms  we  will  describe  the  results  of  examination 
of  stomach  contents.  Here  we  will  only  mention  that,  excepting 
during  attacks,  gastric  digestion  and  appetite  may  be  absolutely 
normal.  If  there  be  a  long  interval  between  the  attacks  of  colic, 
the  patients  may  gain  so  much  in  weight  as  to  mislead  one.  This 
was  particularly  true  of  one  of  my  own  cases.  In  other  patients 
— ^namely,  those  with  increasing  stenosis — the  appetite  very  rap- 
idly diminishes.  This  occurs  partly  in  consequence  of  the  frequent 
paroxysms  of  pain  which  rob  the  patient  of  sleep,  and  partly,  ac- 
cording to  Koenig,  in  consequence  of  auto-intoxication  from  the 
stagnant  fsecal  masses. 

Objective  Symptoms. — These  are :  tumour,  meteorism,  visible 
intestinal  peristalsis,  the  character  of  the  feeces,  and,  in  some  cases, 
the  nature  of  the  stomach  contents. 

The  palpability  of  a  tuTnour,  which^  according  to  Treves^,  occurs 
in  JfO per  cent  of  all  cases  of  cancer  of  the  large  intestine,  constitutes 
one  of  the  most  im,j)ortant  and  decisive  diagnostic  symptoms. 

The  size  of  the  tu7nour  varies  considerably,  from  that  of  a  wal- 
nut to  that  of  a  fist,  or  even  of  a  child's  head.  It  is  hard,  nodular, 
incompressible,  and  more  or  less  painful  on  pressure.  According 
to  all  observers,  its  main  characteristics  are  active  mobility,  and  in 
connection  therewith,  change  of  location  and  position.  The  fol- 
lowing limitations,  however,  must  be  remembered :  the  mobility  of 
new  growths  of  the  large  intestine  is  particularly  well  marked  in 
those  portions  which,  because  of  their  long  mesentery,  themselves 
possess  great  mobility  :  these  are  the  transverse  colon  with  its 
flexures,  and  the  sigmoid  flexure.  The  cgecum  and  the  ascending 
and  descending  colon,  on  account  of  anatomical  peculiarities — 
namely,  their  short,  tense,  retroperitoneal  mesenteries — are  not 
nearly  as  mobile.  Motion  of  the  movable  portions  of  the  intestines 
may  be  restricted  by  adhesions.  Passive  and  active  mobility  is 
increased  by  the  weight  and  pressure  of  the  stagnant  intestinal 
contents  above  the  tumour.  At  times  the  tumour  is  covered  by 
distended  intestine,  so  that  it  may  be  hardly  palpable  or  disap- 
pear entirely ;  hence  repeated  examinations  are  necessary.  This 
condition  is  very  similar  to  that  met  with  in  carcinoma  of  the 
stomach,  in  which  the  tumour  may  not  be  felt  when  the  stomach 
21 


310  DISEASES  OF   THE  INTESTINES 

is  full,  but  becomes  palpable  when  that  organ  is  empty.  Another 
possible  source  of  error  is  that  the  intestines  themselves  fre- 
quently change  their  positions,  and  thus  the  tumour  may  often 
be  falsely  localized.  This  subject,  which  is  of  great  surgical  im- 
portance, will  be  considered  later.  I  shall  now  describe  the  gen- 
eral principles  to  be  followed  in  the  examination  of  intestinal 
tumours  ;  the  technic  has  already  been  considered  (page  84). 

Tumours  of  the  large  intestine  are  best  palpated  when  the  bowel 
is  empty.  When  in  doubt  concerning  the  site  of  the  tumour,  or  its 
differentiation  from  neighbouring  organs  (stomach,  omentum,  kid- 
ney, etc.),  some  aid  may  be  derived  from  filling  the  intestines  with 
air  or  water.  As  already  stated  (page  85),  moderate  inflation 
gives  us  much  "better  information  regarding  the  topography  of 
the  tumour  and  the  position  of  the  affected  segment  than  ex- 
treme inflation.  The  latter  procedure  has  its  dangers  in  ulcer- 
ating tumours.  In  stenosing  cancer  of  the  lower  portion  of 
the  large  intestine,  the  fact  that  air  or  water  repeatedly  intro- 
duced always  returns,  may  clear  up  an  obscure  diagnosis.  Meteor- 
ism  is  another  very  important  diagnostic  symptom.  It  may  be 
localized  or  general.  When  localized,  it  may  enable  us  to  de- 
termine the  site  of  the  stenosis ;  when  general,  the  relations 
between  the  viscera  become  uncertain  and  obliterated.  These 
symptoms  are  more  thoroughly  treated  of  in  the  chapter  on  Intes- 
tinal Stenosis. 

The  occasional  occurrence  of  msihle  intestinal  contractions  ("  in- 
testinal rigidity,"  ISTothnagel)  is  of  great  diagnostic  interest.  These 
contractions  vary  from  a  hardly  noticeable  rigidity  of  the  intestinal 
coils  to  a  plastic  representation  of  one  or  more  of  these,  and  appear 
synchronously  with  the  paroxysms  of  pain  previously  mentioned 
(page  307).  Like  these,  they  vary  greatly  in  duration  and  occur- 
rence. If  contractions  follow  at  frequent  and  regular  intervals, 
their  recognition  is  easy.  If,  on  the  contrary,  they  occur  at  long 
intervals,  as  in  the  beginning  of  stenosis,  unless  clinically  observed, 
their  recognition  is  mostly  the  result  of  accident.  (See  chapter  on 
Intestinal  Stenosis.) 

The  macroscopic  appearance  of  the  fseces  may  be  of  importance  ; 
its  value,  however,  is  negative  rather  than  positive.  The  faecal  masses 
are  generally  not  as  long  nor  as  thick  as  in  normal  stools.  The 
stool  is  passed  in  small,  pointed,  narrow,  or  rounded  masses. 
These  characteristics  are  particularly  noticeable  in  the  stool  from 
enemata.     To  this  there  are,  however,  many  exceptions.     I  have 


INTESTmAL  NEOPLASMS  311 

seen  an  operated  case  of  extreme  stenosis  from  cancer  of  the  caecum, 
in  which  the  cahbre  of  the  stool '  was  absolutely  normal.  After 
passing  the  stenosis,  the  faeces  must  have  become  increased  in  cali- 
bre through  additions. 

The  diagnostic  importance  of  the  passing  of  blood  per  anum 
has,  I  believe,  been  overestimated.  In  only  1  out  of  11  cases  of 
cancer  of  tiie  large  intestine  did  I  observe  blood  in  fairly  large 
quantity.  Slight  losses  of  blood,  usually  overlooked,  may  occur 
more  frequently.  Treves  ^'^,  who  has  had  much  experience  in 
these  affections^  has  found  hemorrhage  in  but  15  per  cent  of  pa- 
tients with  cancer  of  the  colon.  Eüpp^,  in  a  series  of  20  cases,  has 
found  this  symptom  present  in  25  per  cent. 

As  already  mentioned,  the  dejections  may  be  diarrhoeal  in  char- 
acter. This  occurs  not  only  in  cancers  of  the  lower  segment  of 
the  large  intestine,  but,  as  soon  as  marked  ulceration  begins,  also 
in  those  situated  higher  up.  I  have  had  two  opportunities  to 
make  regular  examinations  of  such  stools.  They  are  mottled  red 
in  appearance,  and  at  times  contain  macroscopic,  easily  recognis- 
able admixtures  of  pus,  which  sometimes  forms  as  a  yellow  sedi- 
ment, sharply  contrasted  with  the  remainder  of  the  dejection.  The 
evacuations  were  very  foul,  and  always  of  a  distinctly  alkaline  reac- 
tion. Besides  red  blood-corpuscles,  microscopic  examination  showed 
many  pus  cells  in  every  field,  giving  the  impression  of  an  abscess. 
There  may  be  8,  10,  or  20  such  dejections  daily.  Occasionally  the 
pus  may  not  be  so  prominent,  and  the  stools  are  more  bloody  in 
character,  but  careful  examination  will  always  reveal  pus  in  macro- 
scopic or  microscopic  quantities. 

As  shown  by  cases  of  Potain ^^  and  Wunderlich^,  fragments 
of  the  tumour  may  very  rarely  be  passed  per  rectum,  a  fact  which 
will  at  once  establish  a  positive  diagnosis.  In  a  case  reported  by 
Nicolaysen  ^^,  there  was  prolapse  of  a  carcinoma  of  the  sigmoid 
flexure.  These  cases,  however,  are  so  extremely  infrequent  that  as 
a  rule  they  may  be  left  out  of  diagnostic  consideration.  Despite 
careful  search — both  in  spontaneously  evacuated  stool  and  in 
that  after  rectal  irrigation — I  have  never  found  any  tumour  par- 
ticles. ]^evertheless,  in  all  obscure  diseases  of  the  intestines  in 
which  blood  and  pus  are  present  in  the  evacuations,  I  would  advise 
frequent  rectal  irrigations  for  this  purpose  (see  page  87). 

The  examination  of  the  stomach  contents  may  sometimes  give 
facts  of  diagnostic  importance.  In  cancer  of  the  colon,  as  far  as 
I  know,  no   such  examinations  have  yet   been  made.      In  three 


312  DISEASES  OP  THE  INTESTINES 

patients  in  whom  I  made  the  tests,  the  gastric  motihty  was  con- 
stantly normah  In  one  case  there  was  absence,  and  in  the  two 
others  an  abundance  of  hydrochloric  acid.  I  lay  particular  stress 
upon  the  maintenance  of  good  gastric  motility  in  cancer  of  the 
colon,  since  this,  as  is  well  known,  suffers  quite  early  in  cancer  of 
the  stomach. 

2.   Atypical  Cases  of  Carcinoma  of  the  Large  Intestine 

There  are  many  atypical  cases  in  which  the  clinical  picture  of 
cancer  of  the  large  bowel  is  obscured ;  but,  since  their  detailed 
knowledge  may  enable  us  to  make  a  probable  diagnosis,  they 
must  be  considered.  As  in  cancer  of  the  stomach,  there  is 
often  an  entire  absence  of  characteristic  symptoms :  the  patient 
emaciates,  loses  appetite,  presents  indefinite  dyspeptic  symptoms 
and  continues  to  lose  strength,  and  finally  dies.  Autopsy  shows 
an  intestinal  cancer.  Such  obscure  cases  occur  in  all  segments 
of  the  gas tro -intestinal  canal.  Surgical  literature  contains  many 
examples. 

In  a  second  and  fairly  large  variety  of  cases  there  is  sudden, 
absolute  intestinal  obstruction  with  all  its  serious  sequences.  I 
believe  these  cases  are  more  easily  diagnosticated.  As  early  as 
1864:  Bamberger^  described  one.  After  a  meal  consisting  of 
lentils,  the  patient,  till  then  an  apparently  strong,  healthy  man 
of  forty,  was  suddenly  attacked  with  severe  abdominal  pain,  marked 
tympanitis,  constipation,  and  vomiting.  Death  occurred  on  the  third 
day.  The  autopsy  showed  a  circular,  carcinomatous  stricture  of 
the  sigmoid  flexure  with  only  moderate  stenosis,  but  the  intestine 
above  the  tumour  was  entirely  occluded  by  the  undigested  lentils. 
Rüpp*  has  described  a  series  of  similar  cases  coming  under  his  own 
observation,  characterized  by  acute  intestinal  occlusion  from  cherry 
stones,  bone  splinters,  inspissated  fsecal  masses,  and  apple  seeds. 
Yery  acute  intestinal  obstruction  may  also  result  from  adhesions 
of  the  tumour  to  other  intestinal  coils,  whereby  kinking  or  twist- 
ing of  the  bowel  is  produced. 

As  exemplified  by  a  case  of  Eiipp,  impacted  gallstones  in  the 
small  intestine  may  cause  the  sudden  appearance  of  acute  symp- 
toms of  obstruction  in  a  latent  cancer  of  the  large  bowel.  Such 
instances  might  be  further  multiplied.  Even  without  such  direct 
mechanical  causes,  symptoms  of  complete  obstruction  may  (at 
least  according  to  the  patient's  own  statement)  be  induced  by 
dietetic  errors  in  healthy  or   rather,  apparently  healthy  Individ- 


INTESTINAL  NEOPLASMS  313 

uals.  These  acute  attacks  of  intestinal  obstruction  are  doubt- 
lessly preceded  by  preliminary  symptoms  wbicb  are  only  slight, 
and  impress  the  patient  but  little.  As  far  as  the  patient's 
serious  condition  allows,  the  physician  must  inquire  for  symp- 
toms which  may  have  had  the  character  of  an  incipient  intes- 
tinal stenosis. 

Differential  Diagnosis 

Without  doubt  the  presence  of  a  well-defined  tumour  gener- 
ally facilitates  the  diagnosis ;  although  even  then  error  may  be  una- 
voidable. 

The  question  whether  the  tumour  is  a  real  neoplasm  or  only 
impacted  fseces,  may  sometimes  produce  the  greatest  diagnostic 
difficulties.  In  the  general  division  (page  76)  we  have  described 
the  various  methods  by  which  mistakes  may  usually  be  avoided. 
We  have  there  stated  that  fsecal  accumulations  above  the  stenosis 
may  make  a  neoplasm  appear  much  larger  than  it  really  is. 

Tumours  of  the  coecum^  beginning  like  appendicitis,  with  fever, 
pain  on  pressure,  and  resistance  in  the  ileo-csecal  region,  often  lead 
to  diagnostic  errors.  But  these  tumours  do  not  disappear  when  the 
acute  symptoms  have  passed ;  they  become  larger  and  more  nodu- 
lar, the  patient  emaciates,  and  dies  in  extreme  marasmus,  or  he 
may  succumb  to  symptoms  of  acute  intestinal  obstruction.  Several 
such  cases  have  been  described  by  Bamberger  ^  and  Krausshold  ^. 
Schede^'''  has  observed  a  medullary  cancer  superimposed  upon  an 
old,  irregular  perityphlitis.  On  the  other  hand,  Schede  and  Eiche- 
lot  and  Hartmann  ^^  have  operated  on  cases  in  which,  instead  of 
an  expected  cancer  of  the  csecum,  they  found  only  inflammatory 
perityphlitic  products.  These  cases  demonstrate  that,  even  where 
a  tumour  can  be  felt  there  may  be  difficulties. 

If  there  be  an  intestinal  tumour  the  further  question  of  malig- 
nancy or  benignancy  will  have  to  be  determined.  Kegarding 
benign  tumours,  fibromata  and  myomata  of  the  intestines  are 
very  rare,  and  only  exceptionally  produce  the  severe  symptoms 
of  malignant  growths.  The  differential  diagnosis  between  sar- 
comata of  the  large  and  small  intestines  may  also  have  to  be  made. 
It  is  discussed  under  the  heading  Symptomatology,  to  which  the 
reader  is  referred. 

We  have  already  discussed  the  interesting  and  frequent  question 
of  differentiation  between  cancer  and  tuberculosis  of  the  caecum 
(p.  277). 


314  DISEASES   OP   THE  INTESTINES 

Besides  the  difficulties  already  mentioned,  tumours  of  other  or- 
gans may  give  rise  to  errors  in  diagnosis.  For  example,  von  Berg- 
mann ^^  once  diagnosticated  a  tumour  as  cancer  of  the  c£3cum ;  on 
operation  it  was  found  to  be  a  cancer  of  the  stomach  adherent  to 
the  right  iliac  fossa.  Hahn^  reports  a  case  of  a  yonng  man  of 
nineteen  with  a  nodular  tumour  in  the  right  side  which  was  thought 
to  be  an  enlarged  kidney.  Laparotomy  (Simon's  incision)  showed 
the  right  kidney  normal  and  in  normal  position.  Upon  opening 
the  peritoneum  there  was  found  a  tumour  of  the  ileum  and  cgecum 
the  size  of  a  child's  head.  Examination  proved  it  to  be  a  small 
round-celled  sarcoma.  Czerny  ^'^  and  von  Esmarch  ^  report  similar 
errors.  In  a  doubtful  case  in  a  woman,  in  which  the  diagnosis 
rested  between  tumour  of  the  csecum  and  floating  kidney,  Salzer  ^^, 
on  vaginal  examination,  was  able  to  differentiate  by  involuting  the 
soft  layers  between  his  fingers  and  the  tumour;  he  could  intro- 
duce his  fingers  into  the  ileo-csecal  opening  from  the  small  intes- 
tinal side,  and  thereby  recognised  the  neoplasm  as  one  of  the  csecum. 
These  examples,  particularly  abundant  in  surgical  literature,  might 
be  multiplied. 

The  diagnostic  difficulties  are  increased  when  tumours  of  the 
intestine  (generally  the  large  intestine)  are  complicated  by  displace- 
ment of  the  different  intestinal  segments.  The  obstacles  are  so 
great  that  sometimes  even  an  operation  will  not  clear  up  the 
cases.  Thus,  Passier^  reports  a  case  from  Curschmann's  clinic 
in  which  a  carcinomatous  stenosis  of  the  hepatic  flexure  of  the 
colon  was  clinically  diagnosticated.  Autopsy  revealed  a  carcinom- 
atous degenerated  csecum,  which  was  situated  high  up  under  the 
liver,  and,  owing  to  a  congenital  absence  of  the  ascending  colon, 
communicated  directly  with  the  transverse  colon.  During  an  oper- 
ation for  carcinoma  of  the  large  intestine,  Israel  ^^  thought  he  was 
dealing  with  the  descending  colon,  while,  in  reality,  he  was  oper- 
ating upon  a  displaced  transverse  colon. 

Many  more  examples  might  be  mentioned.  They  should  teach 
us  to  be  very  cautious  in  diagnosticating  the  site  of  a  neoplasm. 
It  may  be  necessary  to  differentiate  between  cancer  of  the  lai'ge 
intestine  and  chronic  intussusception.  The  following  symptoms 
point  to  intussusception  :  sudden  onset,  passing  of  blood  per  rectum, 
shape  of  the  tuaiour  (smooth,  cylindrical)  and  its  spontaneous  mo- 
tility, the  age  of  the  patient.  None  of  these  symptoms  is  pathog- 
nomonic, and  only  by  careful  consideration  of  the  separate  data 
can  a  mistake  in  diagnosis  be  avoided.     Diagnostic  difficulties  may 


INTESTINAL  NEOPLASMS  815 

become  considerable  when  a  tumour  can  not  be  palpated,  and  when 
the  usual  characteristic  symptoms  are  absent.  However,  when 
there  is  a  good  clinical  picture  a  probable  diagnosis  can  be  made. 
To  begin  with,  it  is  necessary  to  establish  the  existence  of  an  intes- 
tinal stenosis.  If  the  symptoms  of  the  latter  are  well  marked, 
we  may  generally  arrive  at  the  correct  diagnosis  by  exclusion. 
Aside  from  subjective  symptoms,  it  is  necessary  to  keep  in  mind, 
first  of  all,  the  appearance  of  visible  intestinal  peristalsis ;  one 
single  coil  of  intestine  discovered  in  the  act  of  peristalsis  and 
rigidity  may  clear  up  an  otherwise  doubtful  condition.  For  the 
different  symptoms  which  occur  in  the  several  varieties  of  intes- 
tinal stenosis  I  refer  the  reader  to  the  chapter  on  Intestinal  Ste- 
nosis. 

If  intestinal  stenosis  is  absent  as  a  symptom,  the  diagnosis  is 
only  possible  from  the  presence  of  other  objective  signs,  particularly 
blood  and  pus  in  the  stools.  As  Nothnagel  *  states,  the  only  other 
disease  besides  cancer  which  can  come  into  question  when  bloody, 
purulent  matter  is  found  in  the  dejections,  is  chronic  dysentery. 
"  Since  dysentery  is  generally  easily  recognised,  the  importance  of 
this  type  of  dejection  in  the  symptomatology  of  intestinal  cancer  is 
quite  manifest." 

The  differentiation  is  not  always  easy,  as  the  following  example 
will  show : 

Mr.  A.,  merchant,  thirty-nine  years  old,  from  Hanover.  Parents  and  grand- 
parents died  at  an  advanced  age ;  has  one  brother  alive  and  well.  Had  measles 
when  a  child.  When  thirteen  years  old  had  malaria  (probably  tertian  type) 
for  eight  to  nine  weeks,  later  disappearing  entirely.  At  twenty-four  had  hem- 
orrhoids, which  were  successfully  ligated.  Otherwise  the  patient  was  well 
until  1896.  At  that  time  he  suffered  with  bowel  complaint— frequent  tenesmus 
without  evacuations,  abdominal  pain,  alternating  constipation  and  diarrhoea. 
Blood  or  pus  had  not  been  observed  in  the  stool.  There  was  then  no  marked  dis- 
turbance of  general  health ;  the  patient  was  not  confined  to  bed ;  he  was  able  to 
attend  to  his  business.  Following  the  use  of  hot  enemata  the  stools  regained 
their  normal  consistency,  and  remained  regular  until  November,  1897.  Patient 
then  for  the  first  time  noticed  the  occurrence  of  frequent  painful  rectal  tenesmus. 
The  dejections  were  liquid,  had  a  very  bad  odour,  and  were  mixed  with  blood 
and  mucus.  The  tenesmus  and  number  of  dejections  gradually  increased. 
Patient  began  to  have  fever;  he  emaciated  and  lost  his  previous  good  appetite. 
I  first  saw  him  on  February  10,  1898;  the  status  pmsens  was  as  follows:  Ex- 
tremely pale,  emaciated  man,  of  medium  size  and  cachectic  facies.  No  enlarged 
glands,  no  cedema,  no  exanthema;  tongue  dry,  clean,  red;  throat  showed  notli- 


*  Log.  cit.  (ref.  6),  p.  236. 


316  DISEASES  OF  THE  INTESTINES 

ing  special;  thorax  long  and  narrow,  percussion  note  normal;  vesicular  breath- 
ing present  all  over  the  lungs.  Heart  sounds  normal ;  heart  of  normal  size. 
Pulse  of  very  low  tension,  small,  somewhat  irregular,  130  beats  per  minute. 
Temperature,  36°  to  37°  C. 

Abdomen. — The  entire  abdomen  unequally  distended.  There  is  distention, 
particularly  localized  below  the  umbilicus.  Occasionally  there  are  seen  indica- 
tions of  intestinal  peristalsis  without  rigidity,  particularly  in  the  ileo-cajcal 
region.  No  tumour  can  be  felt.  Palpation  of  the  ileo-caecal  region  is  very 
painful.  Hepatic  and  splenic  dulness  entirely  absent,  being  obscured  by  the 
tympanitic  intestinal  percussion  note.  Slight  splashing  sounds  in  the  epi- 
gastrium. Rectal  examination  negative.  Rise  of  temperature  between  38° 
and  39°  C. 

Since  his  stay  in  Berlin  the  patient  has  had  continual  rectal  tenesmus. 
There  are  6  to  8  stools  daily,  consisting  at  first  mainly  of  pus  and  blood,  with 
only  a  small  amount  of  faecal  matter  ;  they  have  a  very  foul  and  fetid  odour. 
Microscopical  examination  shows  innumerable  large  and  small  pus  cells  and 
blood  cells.  No  amoebse.  Repeated  examinations  for  tubercle  bacilli  are  nega- 
tive.    Pus  in  the  stool  continues  during  the  course  of  the  disease. 

Urine  contains  a  moderate  amount  of  indican.  Quantity  of  urine,  500  cubic 
centimetres  in  24  hours  ;  it  is  brownish-red  and  of  high  specific  gravity. 

The  course  of  the  disease  was  as  follows :  There  was  quite  apparent  loss 
of  strength ;  at  first  fever,  later  temperature  is  normal  or  subnormal.  Despite 
this  the  pulse  is  always  130-130,  and  very  small;  tongue  clean  but  dry;  abso- 
lute anorexia,  troublesome  thirst  ;  the  main  subjective  symptom  is  tenesmus; 
the  main  objective  symptoms  are  meteorism,  pain  in  the  ileo-csecal  region, 
purulent  dejections,  as  well  as  the  patient's  general  septic  condition  (septic 
intoxication).  With  symptoms  of  increasing  marasmus  and  occasional  somno- 
lence, the  patient  died,  February  36,  1898. 

Autopsy^  February  37th,  performed  by  Dr.  Hans  Kohn,  of  Berlin.  Very 
much  emaciated  corpse,  presenting  nothing  special  externally.  Abdomen  mod- 
erately tympanitic.  The  thin  abdominal  walls  coloured  green.  Upon  opening 
the  abdomen  all  the  intestines  were  found  to  be  distended  with  gas,  and  were 
all  in  normal  position  except  the  sigmoid  flexure,  which  lay  parallel  with  the 
pubic  bone  until  it  reached  the  right  iliac  fossa,  where  it  was  slightly  adherent. 
It  was  also  adherent  to  the  anterior  circumference  of  the  pelvic  outlet.  The 
omentum  was  almost  entirely  free  from  fat  and  wreathlike  in  shape,  and  also 
adherent  to  the  pelvic  outlet.  After  the  omentum  is  thrown  back  the  gen- 
eral intestinal  serosa  is  moist  and  pale,  excepting  over  the  sigmoid,  where 
it  is  very  dark  red.  Attempting  to  loosen  and  free  the  sigmoid,  the  whole 
intestinal  wall  easily  tears,  disclosing  an  abscess  cavity  filled  with  pus  and 
about  the  size  of  a  hen's  egg.  The  walls  of  the  cavity  are  mainly  formed 
by  the  sigmoid  flexure,  and  partly  by  the  anterior  pelvic  floor.  It  communi- 
cates directly  with  the  lumen  of  the  bowel;  the  size  of  the  communication  can 
not  be  positively  determined  because  of  the  extremely  brittle  condition  of  the 
intestinal  wall.  The  dark  discoloration  of  the  intestinal  serosa  extends  up- 
ward to  about  the  beginning  of  the  descending  colon,  whence  it  gradually 
becomes  pale  and  disappears.  With  the  excejjtion  of  the  beginning  of  the 
ascending  colon,  which  is  filled   with   faecal  matter,  the  large  intestine  is 


INTESTINAL  NEOPLASMS  317 

found  to  be  empty,  or  rather  to  contain  only  gas.  The  mucous  membrane 
of  the  descending  colon  is  pale  yellowish- white  in  colour,  and  is  uniformly 
covered  with  thick  pus.  In  numerous  places  there  are  ulcerations,  irregu- 
lar in  shape,  with  smooth  edges,  and  extending  to  the  muscularis.  Above, 
the  ulcers  may  be  followed  into  the  middle  of  the  transverse  colon,  where 
they  become  smaller.  The  smallest  are  the  size  of  lentils,  the  largest  the 
size  of  a  50-cent  piece.  They  are  not  round,  but  irregularly  shaped.  Below, 
the  ulcers  increase  in  size,  and  the  mucous  membrane  becomes  gradually  more 
deeply  injected.  In  the  sigmoid  flexure  the  greater  part  of  the  mucous 
membrane  is  destroyed.  Here  there  are  areas  of  eroded  mucous  membrane 
about  1.3  centimetres  long,  1  to  2  centimetres  broad,  and  about  1  to  3  cen- 
timetres thick. 

As  just  stated,  areas  of  mucous  membrane  and  muscularis  are  entirely 
destroyed.  Between  these  the  mucous  membrane  is  covered  by  reddish-yellow 
thick  pus.  These  changes  extend  into  the  rectum.  The  mucous  membrane 
of  the  upper  portion  of  the  large  intestine,  and  of  the  whole  of  the  small  intes- 
tine, is  anaemic.  The  small  intestine  contains  only  small  quantities  of  semisolid 
masses;  the  contents  of  the  caecum  are  of  normal  consistency,  formed,  rich 
in  fat;  but  in  the  middle  of  the  ascending  colon  the  contents  become  semi- 
solid.    As  already  remarked,  the  intestines  situated  farther  down  are  empty. 

Isolated  lymph  nodes  the  size  of  lentils  are  found  in  the  walls  of  the 
lower  segments  of  the  large  intestine.  Some  of  the  mesenteric  glands  are 
swollen  to  the  size  of  beans.  There  is  no  thrombosis  of  the  blood-vessels 
supplying  the  descending  colon. 

The  liver  is  quite  small  and  soft ;  on  section  it  is  pale,  reddish-yellow,  and 
cloudy;  it  contains  no  abscesses. 

The  spleen  is  somewhat  enlarged,  bluish-red,  and  soft. 

The  right  kidney,  normal  in  size,  but  soft  and  grayish-red  on  section ;  very 
cloudy. 

The  clinical  diagnosis  lay  between  carcinoma,  tuberculosis  of 
the  large  intestine,  and  chronic  dysentery.  Since  tubercle  bacilli 
were  never  found,  and  since  other  signs  of  tuberculosis  were  absent, 
the  diagnosis  was  limited  to  the  two  other  possibilities — carcinoma 
and  dysentery. 

In  my  opinion,  an  epicritical  examination  of  the  case  presents 
no  possibility  of  a  positive  differentiation ;  as  against  cancer  it 
might  be  maintained  that  a  tumour  was  absent.  But  a  tumour,  if 
present,  would  have  been  obscured  by  the  marked  abdominal  dis- 
tention. As  regards  the  fever,  that  would  have  spoken  as  much  for 
the  one  as  for  the  other  condition.  As  to  the  age  of  the  patient, 
there  is  no  special  limit  within  which  cancer  may  occur,  particu- 
larly cancer  of  the  large  intestine.  Finally,  the  course  of  the 
disease  and  its  acute  invasion  spoke  rather  for  than  against  a 
malignant  neoplasm. 


318  DISEASES  OF   THE   INTESTINES 

I  miglit  describe  an  analogous  case,  very  similar  tlirougliont 
except  that  toward  the  end  of  life  there  developed  to  the  right 
of  the  bladder  a  tumour,  whose  diagnosis  caused  ex23ert  clin- 
icians, as  well  as  myself,  many  difficulties.  These  difficulties 
were  increased  by  the  fact  that  the  patient  dated  his  symptoms 
some  fifteen  years  back.  Operation  showed  a  sloughing  carci- 
noma of  the  sigmoid  flexure,  which  had  displaced  the  latter  to 
the  right. 

From  these  two  cases  it  follows  that,  in  the  absence  of  a  tumour, 
the  differential  diagnosis  between  dysentery  and  carcinoma  may 
cause  great  difficulties,  which,  so  far  as  I  can  see,  cannot,  in  the 
present  state  of  medical  knowledge,  be  overcome. 

Finally,  cancer  is  to  be  differentiated  from  the  intestinal  neu- 
roses. I  have  observed  two  cases  which  for  a  long  time  presented 
symptoms  of  nervous  intestinal  disturbance,  and  whose  malignant 
character  was  revealed  only  late  in  the  disease.  Both  patients  had 
suffered  for  years  from  habitual  constipation,  and  both  were  marked 
hypochondriacs  on  the  subject  of  defecation.  Contrary  to  my  own 
opinion,  and  quite  correctly,  they  looked  upon  their  last  complaint 
as  of  a  very  serious  nature.  Brinton's  excellent  dictum  regarding 
cancer  of  the  stomach  is  also  true  of  cancer  of  the  intestine : 
"  Obscure  in  its  symptoms,  frequent  in  its  occurrence,  fatal  in  its 
events." 

(c)    CANCER    OF   THE   RECTUM 

Cancer  of  the  rectum  is  recognised  more  easily  than  cancer  of 
any  other  portion  of  the  intestines,  and  offers  the  most  favourable 
chances  for  cure. 

Symptomatology  and  Diagnosis 

It  is  best  not  to  separate  the  subjective  from  the  objective 
symptoms,  but  to  consider  them  together.  The  subjective  symp- 
toms relate  to  the  disturbances  of  defecation,  and  at  the  beginning 
they  may  be  so  indefinite  that  the  patient  may  not  seek  medical 
advice.* 

Defecation  is  interfered  with  ;  evacuation  occurs  only  after  strong 
action  of  the  abdominal  muscles,  and  the  stools  have  no  longer  the 
normal  cylindrical  form,  but  are  flattened  and  of  small  calibre. 


*  Occasionally  apparently  remote  symptoms  may  point  to  the  real  source  of 
trouble — e.  g.,  obstinate  sciatica. 


INTESTINAL  NEOPLASMS  319 

They  resemble  sheep  dung,  and  are  often  fragmentary.  It  thus 
happens  that  patients  have  frequent  daily  evacuations,  but  each 
time  these  are  small,  unsatisfactory,  and  are  accompanied  by  very 
much  straining.  Closely  related  therewith  is  a  feeling  of  fulness, 
weight,  and  pressure  in  the  small  pelvis,  which  always  impels  the 
patient  to  attempt  to  evacuate  his  bowels.  The  resultant  move- 
ments, though  small,  afford  temporary  relief. 

Gradually  painful  tenesmus  develops,  together  with  the  increas- 
ingly frequent  and  scanty  dejections.  These  may  remain  formed, 
but  usually  consist  of  thin  fluid  masses  with  an  exceedingly  nau- 
seating, fetid  odour.  At  this  time  the  dejections  may  contain  mu- 
cus, blood,  and  pus. 

As  the  disease  progresses  the  symptoms  of  a  stenosis  of  the 
rectum  become  more  marked ;  tenesmus  is  continuous,  or  has 
only  short  remissions.  The  stools  become  more  numerous,  more 
liquid  and  less  in  quantity,  and  admixtures  of  pus,  mucus,  and 
blood  are  more  often  found.  The  symptoms  continue  during  the 
night  and  cause  insomnia.  The  appetite  decreases  perceptibly, 
the  general  health  begins  to  fail,  and  the  patient  begins  to  look 
cachectic. 

The  objective  examination  consists,  first  and  foremost,  of  a  digi- 
tal exploration'  of  the  rectum,  and  then  of  an  examination  of  the 
evacuations. 

At  varying  distances  from  the  anus  the  examining  finger  en- 
counters irregular,  nodular,  thickened  masses  which  are  immedi- 
ately recognised  as  neoplasms.  A  more  careful  examination  will 
distinguish  two  types.  In  cancers  situated  high  up^  the  finger  has 
the  feeling  as  if  entering  a  hard,  rigid  cylinder,  above  and  to  the 
sides  of  which  is  attached,  as  it  were,  a  vaginal  vault.  Generally 
the  finger  cannot  pass  any  farther  through  this  pseudo-vaginal 
opening ;  with  a  little  force  it  may  enter  a  narrow  irregular  cylin- 
der. On  withdrawing  the  finger  there  are  traces  of  blood  and  a 
characteristic  fetid  odour. 

Kraske^  states  that  where  the  carcinoma  is  limited  to  the  wall 
of  the  rectum,  and  is  not  adherent  to  the  surrounding  tissues,  one 
may  obtain  the  sensation  of  ballottement  with  the  end  of  the  finger. 
I  have  found  this  symptom  only  once,  but  this  infrequency  is  pre- 
sumably due  to  the  fact  that  I  generally  see  cases  in  the  more 
advanced  stages  of  the  disease. 

In  cancer  situated  low  down  in  the  rectum  there  is  usually  no 
marked  invagination.     The  finger  enters  a  stiff  walled  cavity  which 


320  DISBASES  OF  THE  INTESTINES 

is  sliarplj  defined  against  the  smooth  mucous  membrane,  both  above 
and  below.  In  other  cases  there  are  circular  or  semicircular  tu- 
mours, with  protuberant,  serrated  (cockscomblike)  edges  which  pro- 
ject beyond  the  normal  mucous  membrane. 

The  diagnosis  of  the  presence  of  cancer  of  the  rectum  is  not 
sufficient ;  it  is  also  necessary  to  know  the  extent  of  the  tumour,  its 
mobility,  and  the  presence  or  absence  of  complications.  The  ques- 
tion of  mobility  is  of  the  greatest  surgical  significance.  According 
to  Kraske,  the  question  of  operation  depends  more  on  the  mobility 
of  the  growth  than  on  its  size. 

The  main  complication  is  rupture  into  the  neighbouring  vis- 
cera (bladder,  genitals).  We  will  not  discuss  the  rarer  complications 
here. 

In  every  case  of  rectal  carcinoma  the  liver  ought  to  be  examined 
as  a  matter  of  routine.  Metastases  occur  most  frequently  in  this 
organ,  a  fact  which  is  naturally  of  great  importance  in  the  question 
of  radical  operation.  Ordinarily  the  examination  of  the  faeces  is 
unnecessary;  but  in  doubtful  tumours,  or  in  those  reached  with 
difficulty,  such  an  examination  may,  as  I  maintain  in  opposition  to 
Hochenegg  ^,  clear  up  the  clinical  picture  to  a  considerable  extent. 
The  external  appearance  of  the  faeces  may  either  be  that  of  stenotic 
stools  (e.  g.,  ribbonlike,  spiral,  short  cylinders  embedded  in  a  thin, 
apparently  homogeneous,  bloody,  or  purulent  ground  substance), 
or  they  may  consist  entirely  of  fluid  or  semifluid  masses,  or,  in  ad- 
vanced cases,  of  pus  and  blood.  In  cases  not  far  advanced,  where 
the  cancer  is  situated  high  up  or  where  the  differential  diagnosis 
lies  between  cancer  and  benign  neoplasm,  the  abnormalities  of  the 
faeces  just  described  are  of  less  significance  than  the  demonstration 
of  small,  microscopic  admixtures  of  pus. 

The  diagnosis,  therefore,  will  not  be  difficult  in  the  majority  of 
cases,  particularly  to  the  physician  who  makes  it  a  rule  to  examine 
the  rectum  digitally  not  only  in  patients  with  symptoms  referred 
to  the  rectum,  but  in  every  case  of  intestinal  disturbance.  There 
are,  however,  isolated  instances  in  which  there  will  exist  doubt  re- 
garding the  nature  of  the  rectal  affection.  These  necessitate  a  short 
discussion  on  differential  diagnosis. 

DlFFEREKTIAL    DIAGNOSIS 

By  careful  and  repeated  rectal  and  vaginal  examinations  it  is 
very  easy  to  differentiate  tumours  of  the  rectum  from  tumours  of 
the  prostate  or  of  the  female  genitals,  pelvic  abscesses,  etc.     Polypi 


INTESTINAL  NEOPLASMS  321 

of  the  rectum  will  only  exceptionally  cause  diagnostic  difficulties. 
Owing  to  their  extreme  rarity,  myomata  of  the  rectum  will  scarcely 
come  up  for  consideration.  Differentiation  from  rectal  sarcoma 
may  give  rise  to  error ;  in  contrast  to  cancer,  the  sarcomatous 
tumour  has  a  smooth  surface  and  there  is  no  tendency  to  ulcer- 
ation. 

It  may  be  somewhat  more  difficult  to  distinguish  between 
fibrous  syphilitic  stricture  of  the  rectum  and  carcinoma.  We  shall 
more  fully  discuss  the  symptomatology  of  syphilitic  stenosis  of  the 
rectum  in  the  chapter  on  Diseases  of  the  Rectum,  and  therefore 
limit  ourselves  here  to  a  few  brief  remarks. 

With  Kraske,  I  believe  that  the  differentiation  is  not  difficult. 
With  reference  to  the  diagnosis,  Kraske  says  the  following,  which 
corresponds  with  my  own  experience :  "  In  syphilitic  proctitis  the 
stenosis  is  produced  by  cicatrization  and  is  a  real  stricture.  The 
difference  between  the  two  forms  of  stenosis  is  also  very  evident  to 
the  examining  finger.  The  syphilitic  ulcerations  never  have  the 
hard,  protuberant  edges  that  are  found  in  the  carcinomatous.  In 
contrast  to  cancer,  syphilitic  ulcers  are  generally  multiple,  and  are 
separated  from  one  another  by  areas  of  healthy  or  cicatrized  mucous 
membrane.  The  syphilitic  infiltration  begins  mainly  as  a  diffuse 
process,  while  cancer  is  for  a  long  time  more  circumscribed.  This 
last  fact  is  particularly  evident  in  the  condition  of  the  surrounding 
tissues  and  organs.  Syphilitic  ulcerations  very  often  produce  peri- 
proctitis, external  abscesses,  and  fistulse  which  rupture  externally, 
while  this  very  rarely  occurs  with  cancer.  In  my  own  experience 
it  has  never  occurred.  It  is  true  that  in  cancer  situated  low  down 
there  may  occasionally  be  a  rupture  through  the  skin  in  the  neigh- 
bourhood of  the  anus,  but  the  character  of  such  an  opening,  par- 
ticularly its  infiltrated  margin,  will  at  once  show  that  it  is  not  a 
fistula  arising  from  a  periproctitic  abscess,  but  is  a  direct  rupture 
due  to  the  growth  of  the  cancer  toward  the  surface."  If  we  add 
further  that  syphilitic  stenosis  is  essentially  chronic,  is  more  fre- 
quent in  women  than  in  men,  is  present  much  earlier  in  life  than 
cancer,  we  have  sufficient  facts  to  assist  us  in  most  cases.  Where, 
despite  the  above,  diagnostic  difficulties  are  encountered,  there  is 
the  final  recourse  to  excision  of  a  piece  of  the  growth  for  examina- 
tion.    Even  this  may  not  give  positive  results. 


322  DISEASES   OP  THE  INTESTINES 

Complications  of  Intestinal  Cancer 

The  most  important  complications  are  produced  by  the  tumour 
itself.  As  already  mentioned  (page  300),  the  tumour  may  become 
adherent  to  the  bladder,  uterus,  ovaries,  stomach,  etc.  There  may 
be  a  discharge  of  fetid  or  fsecal  matter  through  these  organs.  I  have 
seen  two  cases  of  rupture  of  cancer  into  the  bladder  with  the  rapid 
development  of  a  parulent  cystitis  with  extremely  feculent  urine. 
When  rupture  into  the  uterus  or  vagina  takes  place,  fsecal  masses 
empty  themselves  through  the  genital  cloaca.  Where  a  communica- 
tion between  the  stomach  and  large  intestine  is  established  the  condi- 
tion of  lientery,  known  to  the  older  writers,  develops.  In  consequence 
of  such  a  fistula  there  is  fsecal  vomiting,  and  the  passing  of  entirely 
undigested  food  per  anum.  Rarely,  carcinoma  may  rupture  through 
the  abdominal  wall.  Finally,  there  may  be  a  rupture  of  the  carci- 
noma into  the  retroperitoneal  tissue,  with  the  formation  of  fsecal 
abscesses.  The  latter  may  cause  a  general  septic  peritonitis,  or 
may  lead  to  abscesses  pointing  at  different  places  —  e.  g.,  Pou- 
part's  ligament,  the  lumbar  region,  etc.  The  perforation,  per  se, 
is  practically  the  most  important  as  well  as  the  most  significant 
complication.  This  may  occur  very  suddenly,  without  any  warn- 
ing, when  the  patient  seems  to  be  im23roving.  In  one  case  per- 
foration occurred  during  the  time  the  attendants  were  giving  the 
patient  an  enema  of  water.  Straining  at  stool  may  c^use  this  un- 
expected accident. 

Finally,  death  may  be  caused  by  rarer  complications,  viz.,  aspi- 
ration pneumonia,  embolism  and  venous  thrombosis,  ursemia,  metas- 
tases in  other  organs,  peritoneal  carcinoma,  terminal  hemorrhage 
of  the  intestine,  stomach,  etc. 

Treatment  of  Intestinal  Cancer 

In  the  ordinary  sense  of  the  word  a  real  cure  of  an  intestinal 
cancer  does  not  exist.  Under  favourable  conditions,  to  be  later 
more  fully  described,  extirpation  of  the  tumour  may  prolong  life 
for  months,  or  years,  but  even  in  these  cases  a  fatal  termination 
cannot  be  prevented.  With  but  few  exceptions,  surgical  inter- 
ference is  the  best  and  most  practical  of  all  the  palliative,  life- 
prolonging  remedies.  In  most  surgical  operations  there  is  un- 
deniably a  direct  relation  between  the  object  to  be  gained  and 
the  severity  of   the   operation.      He  who  risks  much  may  occa- 


INTESTINAL  NEOPLASMS  323 

sionally  expect  a  successful  result  even  under  unfavourable  cir- 
cumstances ;  he  who  does  not  take  such  risks  cannot  reckon  on 
great  results. 

In  hopeless  cases  we  must  limit  ourselves  to  palliative  treatment. 
The  various  palliative  measures  depend  upon  the  site  of  the  tumour 
and  the  clinical  syndrome. 

They  consist  in 

1.  Increasing  the  patient's  strength. 

2.  Kemoval  of  the  stenotic  symptoms  present  in  the  great  ma- 
jority of  cases. 

3.  When  the  last  object  is  only  partially  accomplished  or  im- 
possible, relief  of  the  pain  and  other  symptoms  caused  by  the  ste- 
nosis. 

4.  Treatment  and  relief  of  complications. 

It  is  quite  apparent  that  the  above  division  is  somewhat  sche- 
matic, since  the  several  symptoms  may  change  or  become  interde- 
pendent. For  the  better  survey  of  the  subject  we  shall,  however, 
adhere  to  this  grouping. 

1.  In  many  cases  the  attempt  to  increase  the  strength  and 
nutrition  succeeds  even  though  temporarily.  For  apparent  reasons 
we  are  least  successful  in  cancer  of  the  small  intestine,  and  most 
successful  in  cancer  of  the  rectum,  while  cancer  of  the  large  intes- 
tine occupies  a  middle  ground. 

In  cancer  of  the  small  intestine  the  diet  is  similar  to  that 
in  cancer  of  the  stomach.  It  consists  in  the  frequent  adminis- 
tration of  small  quantities  of  fluid  or  semisolid  nourishment  of 
the  highest  caloric  value.  To  stimulate  the  appetite  we  must 
consider  the  wishes  and  peculiarities  of  the  patient.  We  should 
not  hesitate  to  give  patients  such  food  as  may  refresh  and  please 
them,  provided  it  does  not  aggravate  the  intestinal  lesion  (von 
Leyden). 

The  underlying  principles  have  already  been  given  (page  151), 
and  it  will  only  be  necessary  to  describe  several  minor  details. 
In  carcinoma  of  the  duodenum  those  foods  are  most  appropriate 
which,  because  of  their  physical  character,  allow  of  a  large  con- 
centration of  soluble  nourishment.  Milk,  albumin,  carbohydrates, 
and  fats,  percentages  of  which  may  be  increased  at  will,  occupy  the 
first  place. 

The  albumin  may  be  increased  in  amount  by  the  addition  of 
commercial  albumin  preparations ;  the  carbohydrates,  by  the  addi- 
tion of  flour  in  any  of  its  many  well-known  forms  ;  the  fats,  by 


324  DISEASES  OF  THE  INTESTINES 

addition  of  cream  in  amounts  depending  upon  the  tolerance  of  the 
stomach  and  the  degree  of  stenosis.  Both  the  albumin  and  car- 
bohydrates can  be  simultaneously  increased  by  adding  leguminous 
flour. 

The  artificial  albumin  preparations,  often  tiresome  in  dyspeptic 
conditions,  may  be  alternated  with  natural  egg  albumen.  Yege- 
table,  meat,  and  fish  soups  in  their  many  combinations  may  be  given 
to  satisfy  the  patient's  desire  for  change  of  diet  without  producing 
an  appreciable  diminution  of  the  general  nutrition.  Solid  meat  and 
fish  preparations  should  be  administered  in  their  most  easily  digest- 
ible forms,  or  had  better  be  avoided  altogether.  Vegetables  and 
fruits,  white  bread,  zwieback,  sweetened  crackers,  all  of  which  have 
been  finely  divided  or  thoroughly  cooked,  may  be  allowed.  Raw 
fruits,  vegetables,  tubers,  and  similar  articles  are  to  be  absolutely 
forbidden.     We  shall  return  to  this  subject. 

The  food  given  to  patients  with  cancer  of  the  rectum  and  other 
portions  of  the  large  intestine  may  be  much  more  varied.  As  we 
have  already  seen,  the  stomach  functions  may  be  absolutely  normal  in 
these  cases,  and  a  similar  normal  condition  may  be  assumed  to  exist 
in  the  upper  part  of  the  intestinal  canal.  The  diet  must  be  of  the 
greatest  caloric  value,  but  the  food  need  not  necessarily  be  given  in 
small  quantities  and  with  frequent  intervals.  With  the  exceptions 
soon  to  be  stated  the  foods  may  be  given  in  their  natural  form. 
Meat,  when  minced,  is  often  easily  digested.  Soups,  particularly 
when  concentrated,  are  good  though  by  no  means  absolutely  neces- 
sary forms  of  diet.  The  same  may  be  said  of  milk,  though  strength- 
ening the  patient.  Unfortunately  milk  is  not  always  well  borne ; 
in  such  instances  it  may  be  tried  in  its  various  preparations  (kefyr, 
sour  milk,  koumyss,  etc.). 

Vegetables,  lohich  in  their  natural  form  are  not  finely  divided, 
must  alvKtys  he  strained,  so  as  to  jprevent  any  possihle  mechanical 
obst/ruction  of  the  luTuen  of  the  intestine. 

For  this  reason  vegetables  which  cannot  be  mashed  should  be 
absolutely  excluded ;  in  fact,  I  regard  it  as  a  distinct  therapeutical 
error  to  allow  patients  Avith  intestinal  stenosis  to  eat  unstrained  len- 
tils, peas,  beans,  asparagus,  raw  fruit,  cabbage,  etc.  This  same  is 
true,  possibly  more  so,  when  applied  to  raw  compotes,  or  such  as  are 
not  rendered  fully  pultaceous,  or  compotes  and  fruit  containing 
small  seeds.  As  shown  above,  the  patients  may  pay  for  such  in- 
discretions with  their  lives. 

2.  Next  to  abundant  nourishment,  the  physician  must  try  to 


INTESTINAL   NEOPLASMS  325 

induce  increased  intestinal  peristalsis,  brought  about,  if  possible, 
bj  dietetic  means.  We  have  fully  described  this  in  the  General 
Division  (see  page  151,  etc.). 

To  a  certain  degree  diet  may  remove  the  symptoms  due  to  the 
stenosis.  The  underlying  dietary  principles  have  already  been  con- 
sidered in  the  General  Division,  and  in  the  chapter  on  Intestinal 
Stenosis.  The  functional  disturbances  from  intestinal  cancer  re- 
quire great  caution,  for  to  the  putrefaction  produced  by  the  stenosis 
there  is  often  added  that  resulting  from  the  intestinal  ulcerations. 
Thus,  instead  of  the  normal  contents,  the  bowel  contains  a  fetid 
mixture,  uninfluenced  by  intra-intestinal  medication.  It  is  advis- 
able to  get  rid  of  this  putrescent  material  as  soon  as  possible  by 
lavage  of  the  stomach  in  cancer  of  the  upper  intestinal  segments, 
and  by  appropriate  laxatives  when  the  cancer  is  in  the  lower  seg- 
ments of  the  intestine. 

3.  When  the  above  measures  fail  to  relieve  the  symptoms  of 
stenosis,  the  use  of  narcotics  is  oftentimes  unavoidable.  We  must 
again  refer  the  reader  to  the  chapter  on  Intestinal  Stenosis  and  to 
the  General  Division. 

In  the  operative  treatinent  of  intestinal  carcinoma  the  following 
indications  are  particularly  to  be  considered  : 

1.  Extirpation  of  the  tumour. 

2.  The  removal  of  stenotic  symptoms. 

3.  Relief  of  intestinal  obstruction  which  may  develop  during 
the  course  of  the  disease. 

Before  discussing  the  indications,  we  must  briefly  narrate  the 
results  of  intestinal  surgery,  as  found  in  the  numerous  clinical  and 
statistical  reports. 

The  medical  practitioner,  even  though  thoroughly  acquainted 
with  the  various  phases  of  the  disease,  will  rarely  have  an  extensive 
personal  experience  therevdth.  Hence,  notwithstanding  the  well- 
known  and  oft-repeated  fact  that  statistics  are  not  always  complete 
or  reliable,  it  is  necessary  for  him  to  study  statistical  reports. 

In  the  first  place,  the  results  of  operations  for  cancer  vary 
with  the  kind  of  operation.  According  to  Wölfler  *^,  the  latest 
statistics  on  intestinal  resection  for  new  growths  give  the  high 
mortality  of  54  per  cent,  while  the  entire  mortality  of  intestinal 
resections  for  all  causes  is  only  39.5  per  cent.  As  pointed  out  by 
many  writers  (Mikuhcz  and  others),  this  mortality  is  influenced 
by  the  nature  of  the  disease.  In  this  connection  it  is  worthy  of 
notice  that  better  technic  shows  no  improvement  in  results.  In 
22 


326  DISEASES   OP   THE  INTESTINES 

1890  Billrotli^  reported  a  mortality  of  50  per  cent;  Czerny^^,  a 
similar  mortality  in  1892.  Nicolaysen  ^  gathered  together  121  cases 
from  literature,  with  a  mortality  of  48  per  cent.  My  own  expe- 
rience is  limited  to  8  operations  for  cancer  of  the  large  intestine 
(csecum,  5 ;  hepatic  flexure,  2 ;  sigmoid  flexure,  1),  of  which  3 
were  resected.  One  case,  cured  by  resection,  is  now  alive,  four 
years  since  operation  ;  2  died  several  days  after  operation ;  intes- 
tinal anastomosis  was  performed  in  2  cases  (they  lived  eight  or 
nine  months) ;  in  2,  enterostomy  (colostomy)  was  performed  during 
an  attack  of  acute  intestinal  obstruction ;  in  another,  exploratory 
laparotomy. 

The  chances  for  a  permanent  cure  after  resection,  are  evidently 
more  favourable  in  intestinal  than  in  gastric  cancer,  because  the 
former  has  a  lesser  tendency  to  metastasis.  Wölfler  reports  a 
case  of  a  man  operated  on  for  cancer  of  the  sigmoid  flexure  in 
1879  who  was  still  well  in  1896.  Riipp*  reports  a  case  of  a 
patient  from  Krönlein's  clinic,  who  after  nine  years  had  had  no 
relapse.  From  reports  kindly  sent  me  by  Prof.  Körte,  of  Berlin,  I 
learned  that  an  almost  hopeless  case  of  cancer  of  the  caecum  had 
been  operated  on  and  had  now  been  well  over  nine  years.  There 
are  many  other  similar  accounts  of  patients  operated  on  for  cancer 
of  the  large  intestine  who  remained  cured  for  a  number  of  years 
(Billroth,  König,  Czerny,  Wölfler,  and  others). 

The  results  from  incomplete  enterostomy  (the  entero-anasto- 
mosis  of  Maisonneuve)  are  much  more  favourable.  Wölfler*''' 
cites  statistics  of  Schloffer,  which  show  that  in  4Y  cases  of  intes- 
tinal stenosis  the  mortality  from  this  operation  was  only  30  per 
cent.  The  duration  of  the  cure  seems  on  the  whole  to  be  favour- 
able. In  one  case  of  Körte*  (cancer  of  the  splenic  flexure)  the 
patient  lived  three  and  a  quarter  years  after  entero-anastomosis ; 
he  died  finally  of  metastatic  cancer  of  the  liver.  The  result  in 
these  cases  is  to  be  judged  by  the  degree  of  restoration  of  function. 
Unfortunately  there  are  only  a  few  useful  reports  in  this  connection. 
In  the  two  cases  I  have  mentioned  above  the  results  were  not  satis- 
factory. The  patients  gained  in  weight,  although  the  intestinal 
pains  were  in  no  wise  decreased.  In  one  of  the  cases  evidences 
of  intestinal  stenosis  reappeared  after  a  time. 

The  results  of  operative  treatment  of  rectal  cancer  require 
special  mention.     We  distinguish  the  following  methods  : 

*  Personal  report. 


INTESTINAL   NEOPLASMS  327 

1.  Extirpation  of  the  rectum  by  the  perineal  method,  practised 
in  rectal  tumours  situated  low  down. 

2.  Extirpation  by  the  sacral  method,  first  introduced  by  Kraske^ 
for  rectal  cancer  situated  high  up  ;  the  operation  has  been  improved 
by  the  further  modifications  of  Hochenegg^^,  v.  Heinecke  ^^,  W. 
Levy^^,  Schlange^,  [Bardenheuer]  and  others, 

3.  The  vaginal  method  recently  introduced  by  Eehn  ^^  for  the 
removal  of  rectal  cancer  in  women. 

There  are  a  number  of  statistics  regarding  the  results  from  the 
first  of  the  above-mentioned  surgical  procedures.  We  limit  our- 
selves to  the  very  extensive  statistics  from  Czerny's  clinic  ^^,  which 
have  the  advantages  of  presenting  the  results  of  only  one  individual, 
of  covering  a  long  period  of  time,  and  of  including  both  methods 
of  operation.  From  18Y8  to  1891  152  cases  of  rectal  cancer  came 
under  observation,  of  which  number  radical  operation  was  per- 
formed in  109,  21  were  curetted,  12  were  inoperable,  and  colotomy 
was  performed  in  8.  Of  83  cases  operated  by  the  perineal  method, 
3  died  immediately  (that  is,  3.6  per  cent).  Of  66  cases  operated  on 
by  the  sacral  method,  9  died  (13.61:  per  cent).  The  total  mortality 
of  the  109  cases  was  10,  or  9.1  per  cent.  Of  99  patients  radically 
operated  on,  21  lived  two  years  or  more ;  15  lived  three  years  or 
more ;  8,  five  years  and  over ;  1,  eighteen  years ;  another,  sixteen 
years ;  others,  thirteen  and  three  quarters,  eleven  and  a  half,  eight 
and  three  quarters,  and  six  and  three  quarters  years.  The  frequency 
of  recurrence  after  extirpation  is  very  variously  estimated  by  the 
different  authors.  The  percentage  ranges  between  41.6  per  cent 
(Kraske)  and  73.3  per  cent  (Lövinsohn).  According  to  Czerny^''^ 
these  figures  underestimate  the  facts ;  he  claims  that  20  to  25  per 
cent  of  radically  operated  cases  remain  free  from  recurrence  for 
over  two  years,  and  that  the  majority  of  these  remain  permanently 
cured.  The  danger  of  recurrence  is  diminished  by  the  sacral  method 
of  operation,  since  by  this  procedure  the  lymph  nodes  in  the  sacral 
fossa  can  also  be  removed.  But  the  value  of  extirpation  of  the 
rectum  is  also  determined  by  the  functional  results  obtained.  Un- 
fortunately, there  are  not  sufficient  statistics  in  this  connection  to 
permit  of  proper  judgment.  The  functional  results  depend  upon 
whether  the  sphincter  ani  must  be  sacrificed  or  not.  When  the 
sphincter  can  be  saved  the  functional  result  is  satisfactory,  even 
though  the  sphincter  rarely  contracts  as  well  as  the  normal.  When 
the  sphincter  has  been  sacrificed,  the  condition  of  the  patients  is 
extremely  unfortunate,  since  they  have  absolutely  no  control  over 


328  DISEASES   OF   THE   INTESTINES 

the  flatus  or  fluid  stools.  Solid  faeces  can  usually  be  controlled  by 
tlie  formation  of  an  elastic  obstruction  near  the  former  third 
sphincter,  the  rectum  being  then  daily  irrigated. 

Regarding  extirpation  of  the  tumour,  whether  of  the  small  in- 
testine, colon,  or  rectum,  the  operation  must  be  radically  performed 
in  those  cases  in  which  the  tumour  is  well  circumscribed  and  mov- 
able, and  where  no  metastases  are  found. 

As  is  well  known,  apparently  favourable  cases  may,  when 
laparotomized,  present  evidences  of  metastases,  ascites,  and  peri- 
toneal carcinoma — conditions  which  make  radical  operation  illu- 
sory. When  an  early  diagnosis  has  been  made,  it  is  inadvisable  to 
delay  operation,  for,  aside  from  favourable  local  conditions,  resec- 
tion of  the  intestine  requires  endurance  and  strength  on  the  part 
of  the  patient.  Unfortunately,  the  absence  of  these  qualities  fre- 
quently renders  radical  operation  impossible. 

The  second  indication  for  operation  is  increasing  stenosis.  In 
these  cases  a  radical  operation  cannot  be  performed,  either  because 
adhesions  make  the  removal  of  the  tumour  very  difiicult,  or  metas- 
tases are  already  present,  or  the  weakened  condition  of  the  patient 
does  not  allow  of  a  severe  operation.  In  cancer  of  the  small  intes- 
tine gastro-enterostomy  or  entero-anastomosis  comes  in  question  ; 
in  cancer  of  the  large  intestine  (including  the  sigmoid  flexure), 
entero-anastomosis  or  colostomy ;  while  in  cancer  of  the  rectum 
only  colostomy.  In  rectal  cancer  some  surgeons  advise  scraping  or 
electrolytic  removal  of  the  stenosing  tumour  masses,  but  others  of 
experience  (among  them  Kraske  and  Czerny)  advise  against  such 
procedures. 

When  there  is  danger  of  intestinal  obstruction  or  when  it  is 
already  present,  enterostomy  or  colostomy  is  generally  indicated. 

Finally,  regarding  extirpation  of  rectal  cancer,  the  indications  to 
operate  are  influenced  more  by  the  mobility  of  the  tumour  than  by 
its  extent.  In  many  cases  examination  under  narcosis  is  necessary 
to  decide  the  question  of  operahility  and  the  character  of  the  sur- 
gical procedure  to  be  used.  In  all  obscure  cases  it  is  best  for  the 
medical  practitioner  and  surgeon  to  consult,  and  together  determine 
the  mo.de  of  operation. 

The  experienced  medical  practitioner  can  generally  recognise 
inoperable  cases  of  cancer  of  the  rectum  ;  the  extensive,  rigid,  fis- 
sured, ulcerated,  absolutely  immovable  neoplasm  leaves  no  room  for 
indecision.     In  these  cases  we  must  decide  whether  a  colostomy  is 


INTESTINAL   NEOPLASMS  329 

to  be  performed,  or  whether  the  patients  are  to  be  left  to  their 
fate.  The  decision  is  by  no  means  an  easy  one  ;  each  individual 
case  must  be  carefully  considered,  not  only  respecting  the  condition 
of  the  rectum,  but  also  the  personality  of  the  individual.  Consid- 
ering the  unfavourable  cosmetic  result,  some  surgeons  strongly 
advise  against  colostomy,  and  only  resort  to  the  operation  vrhen  an 
almost  complete  stenosis  is  present. 

Kraske^  says  :  "  It  is  horrible,  even  for  a  person  of  phlegmatic 
temperament,  to  witness  daily  the  misery  caused  by  tbe  involuntary 
evacuation  of  faeces,  and  to  know  besides  that  a  progressive  and 
fatal  disease  is  present."  Frequently,  however,  patients  are  satis- 
fied witb  their  condition  after  operation. 

II.    Sarcoma  and  Lymphosarcoma  of  the   Intestine 

According  to  Kundrat  ^,  the  best  authority  on  these  neoplasms, 
sarcoma  and  lymphosarcoma  belong  to  the  rarer  intestinal  tumours. 
Out  of  the  large  material  of  the  Vienna  General  Hospital,  he  could 
collect  only  3  sarcomata  and  9  lymphosarcomata  of  the  intestine 
between  the  years  1882  and  1893. 

Regarding  the  localization  of  sarcoma,  l^othnagel  *  voices  the 
general  opinion  when  he  states  that  the  majority  of  cases  are  found 
in  the  small  intestine,  and  only  extremely  rarely  are  they  in  the 
large  intestine. f  This  view  is  correct  if  we  exclude  the  i*ectum, 
where  sarcomata  are  found  as  frequently  as  in  the  upper  part  of 
the  intestinal  canal.  This  conclusion  is  drawn  from  the  careful 
work  of  Fr.  Krüger  ^^,  who  has  tabulated  all  the  known  cases  of 
intestinal  sarcoma  reported  up  to  the  year  1894 — altogether  37. 
These  tumours  were  distributed  as  follows  : 

Small  intestine 16 

Ileum  and  caecum 1 

Caecum 1  (2) :{: 

Yermiforra  appendix 1 

Transverse  colon 1 

Small  and  large  intestine 1 

Rectum 16 

*  Loc.  eit.,  p.  250. 

f  [Libman,  American  Journal  of  the  Medical  Sciences,  September,  1900.  p.  309, 
publishes  an  interesting  report  of  four  cases  with  detailed  discussion  of  the  clinical 
and  histological  aspects  of  sarcoma  of  the  small  intestine,  together  with  an  exten- 
sive reference  to  the  literature  of  the  subject. — Tr.] 

X  A  case  reported  by  Carrington  (cited  by  Baltzer,  Archiv  für  klin.  Chir.,  vol. 
xliv,  p.  744)  has  here  escaped  notice. 


330  DISEASES  OF   THE  TNTESTINES 

The  ages  of  the  patients  were  as  follows  : 

3  cases  in  the  first        decade. 


3 

(( 

second 

6 

u 

third 

.0 

ii 

fourth 

5 

u 

fifth 

6 

ii 

sixth 

4 

ii 

seventh 

If  we  may  judge  from  these  rather  few  statistics,  we  see 
that  the  first  decades  by  no  means  furnish  so  large  a  majority 
of  the  cases  as  is  commonly  believed.  Furthermore,  in  contrast 
to  cancer,  the  proportion  of  the  male  and  female  cases  is  striking 
(31  :  6). 

Regarding  the  type  of  intestinal  sarcoma,  all  possible  forms 
may  be  observed — hard  and  soft,  small  and  large  spindle-celled, 
small  and  large  round-celled,  alveolar  and  medullary,  melano-  and 
cystosarcoma  (Krüger).  The  round-  and  spindle-celled  forms* 
are  the  most  frequent.  They  generally  originate  in  the  submucosa, 
extending  inwardly  to  the  tunica  propria  and  outwardly  to  the  mus- 
cularis.  Some  forms  originate  in  the  subserosa,  and  sj^read  inwardly 
from  here. 

The  sarcomatous  tumour  is  usually  smooth  and  its  size  va.ries. 
It  is  often  enormous.  At  different  places  it  presents  softened 
areas.  It  is  not  particularly  painful,  is  frequently  movable,  and,  in 
contrast  to  cancer,  is  distinguished  by  its  rapid  growth. 

Zy?njyhosareomata  probably  originate  from  the  lymphatic  sys- 
tem of  the  intestines.  As  already  indicated  by  the  difference  of 
their  development,  the  changes  produced  in  the  intestinal  canal  by 
sarcomata  and  lymphosarcomata  are  quite  different  from  those  of 
cancer. 

In  cancer  there  is  a  circular,  relatively  well-defined  area  of  dis- 
ease ;  in  sarcoma  and  lymphosarcoma  the  affected  area  is  extensive 
and  indefinite.  As  a  result  of  this  circular  form  of  the  cancerous 
tumour  a  stenosis  results.  In  sarcoma,  however,  as  pointed  out  by 
Treves,  and  later  also  by  Baltzer^  and  Madelung^,  there  is  almost 
always  more  or  less  demonstrable  stretching  and  dilatation  of  the 
intestinal  luinen.     As  demonstrated  by  Bessel-Hagen ^^  in  a  case  he 

*  For  further  histological  details  I  would  refer  to  the  text-books  on  pathological 
anatomy ;  also  particularly  to  the  article  by  Ackermann,  Die  Histogenesis  und  His- 
tologie der  Sarcome,  Yolkmann's  Samml.  klin.  Vorträge,  pp.  233,  234. 


INTESTINAL  NEOPLASMS  331 

reported,  the  dilatation  may  become  enormous.  Sarcoma  is  much 
more  apt  to  form  metastases  than  is  cancer,  but,  on  the  whole,  this 
occurs  late  in  the  disease.  Lymphosarcoma,  on  the  other  hand, 
seems  to  attack  only  the  surrounding  lymph  glands. 

The  question  of  the  relation  between  tuberculosis  and  lympho- 
sarcomata  is  a  peculiar  one  and  has  recently  caused  lively  discussion. 
The  observations  of  A.  Müller ^^,  Clans'^,  Kicker^,  Nothnagel,^ 
Dietrich  ^^,  and  Rud.  Schmidt  ^^,  point  to  the  possible  coincidence  of 
tuberculosis  and  lymphosarcomatosis. 

Hereditary  tuberculosis  is  sometimes  found  in  the  family  his- 
tory. A  direct  connection  between  the  two  diseases  seems  to  be 
excluded ;  still  there  is  much  in  favour  of  the  theory  advanced,  par- 
ticularly by  Rudolf  Schmidt,  that  there  probably  exist  hereditary 
constitutional  tendencies — that  is,  a  sort  of  lessened  power  of  resist- 
ance of  the  entire  lymphatic  system. 

The  duration  of  intestinal  sarcoma  is  shorter  than  that  of  can- 
cer ;  most  patients  die  within  one  year  of  cachexia,  metastases,  etc. 

Symptomatology,  Diagnosis,  and  Differential  Diagnosis 

The  suhjecti've  symptoms  of  sarcoma  of  the  small  intestine  pre- 
sent but  few  characteristic  features.  They  consist  in  diffuse  ab- 
dominal pain,  nausea,  vomiting  (oftentimes  said  to  be  bilious  m 
character),  and  marked  irregularity  of  the  bowels — obstinate  consti- 
pation alternating  with  profuse  diarrhoea.  Where  constipation 
alone  was  present,  complications  were  always  found  (invagination 
or  intestinal  displacements).  The  most  important  objective  symp- 
toms are  the  tumour,  intestinal  symptoms,  and  rapidly  developed 
debility.  In  contrast  to  cancer  the  tumour  is  smooth,  and  often 
softened  areas  are  to  be  felt ;  it  is  well  defined  and  easily  mova- 
ble. Several  cases  have  been  reported  (Madelung)  in  which  there 
was  evident  growth  of  the  tumour  within  a  few  days. 

As  is  apparent  from  the  above,  the  absence  of  the  symptoms  of 
stenosis  is  a  characteristic  of  great  diagnostic  importance ;  visible 
intestinal  peristalsis  and  intestinal  impactions  are  also  absent.  On 
the  other  hand,  the  extensive  growth  of  the  sarcoma  may  cause 
severe  intestinal  paralysis. 

To  judge  from  a  review  of  the  histories  of  reported  cases,  the 
absence  of  intestinal  hemorrhage  is  of  some  diagnostic  significance, 
since  this  symptom  is  rather  frequent  in  cancer.     The  very  rapidly 

*  Loc.  cit.,  p.  253. 


332  DISEASES   OF   THE  INTESTINES 

developed  cachexia  is  a  striking  symptom ;  it  may  become  extreme 
within  a  few  weeks  or  months. 

Other  symptoms  of  possible  diagnostic  value  are  temporary 
(Edema  of  the  ankles,  the  early  occurrence  of  ascites,  and  occa- 
sionally an  irregular  fever  (up  to  39.5°  C.  in  a  case  of  Madelung's). 
I  find  oedema  of  the  ankles  mentioned  as  a  symptom  in  six  of 
Krüger's^^  cases. 

The  recognition  of  lymphosarcoma  is  very  difficult,  for,  as 
shown  by  a  study  of  the  cases  published,  its  symptoms  may  be 
quite  different  from  those  of  sarcoma.  Two  examples  of  this  are 
reported  from  Neusser's  cHnic  in  the  above-mentioned  work  of 
Rudolf  Schmidt  ^^.  Despite  the  greatest  care,  a  correct  diagnosis 
was  not  made.  It  is  worthy  of  note  that  in  the  first  of  these  two 
patients  attacks  of  painful  colic,  inaugurated  by  distressing  intestinal 
contraction  and  very  loud  borborygmi,  were  present.  The  diag- 
nosis lay  between  intestinal  sarcoma  and  cancer.  The  autopsj 
showed  a  stenosis,  which,  however,  was  not  produced  by  the  neo- 
plasm, but  by  adhesions  of  two  sarcomatous  degenerated  coils  of 
intestine.  In  the  second  case,  complicated  by  tuberculosis  of  the 
pulmonary  apices,  the  clinical  picture  was  that  of  peritoneal  tuber- 
culosis.    (Edema  was  present  in  both  instances. 

Naturally  the  presence  of  a  tumour  is  indispensable  for  the 
diagnosfs ;  a  tumour  in  the  second  case  might  have  made  diagnosis 
possible.  The  above  coincidence  of  pulmonary  tuberculosis  and 
lymphosarcoma  shows  the  importance  of  a  careful  history.  When 
a  characteristic  tumour  is  present,  the  diagnosis  of  sarcoma  of  the 
small  intestine  presents  no  insurmountable  difficulties,  particu- 
larly when  the  age,  rapid  development,  and  absence  of  stenotic 
symptoms  are  taken  into  consideration.*  When  a  well-defined 
tumour  is  absent  a  correct  diagnosis  is  only  accidental,  although 
the  course  of  the  disease  may  justify  the  diagnosis  of  a  malignant 
affection. 

When  tuberculosis  is  present  or  suspected,  particularly  when 

*  [Even  in  a  young  person  presenting  a  tumour  the  diagnosis  is  by  no  means 
always  possible.  Two  of  Libman's  cases  (loe.  cit.)  very  closely  simulated  appendi- 
citis. In  the  one,  M.  G.,  age  18  years,  there  was  a  history  of  only  one  day's  stand- 
ing, with  such  acute  symptoms  that  the  case  was  thought  to  be  a  perforated  appen- 
dicitis. In  a  third  case  the  diagnosis  lay  between  sarcoma  of  the  kidney,  tubercu- 
lar peritonitis,  and  sarcoma  of  the  peritoneum,  with  possible  primary  tumour  of 
the  intestine.  It  must  be  remembered,  too,  that  cancer  of  the  intestine  is  by  no 
means  rarely  met  with  in  young  individuals  (see  p.  297).— Tr.] 


INTESTINAL   NEOPLASMS  333 

a  serous  effusion  is  present,  the  diagnosis  will  often  lie  between 
peritoneal  tuberculosis  and  an  obscure  abdominal  tumour  (cancer, 
sarcoma,  lymphosarcoma).  The  coincidence  of  tuberculosis  and 
lymphosarcoma  has  already  been  mentioned. 

Treatment 

The  treatment  of  intestinal  sarcoma  and  lymphosarcoma  is 
not  different  from  that  of  cancer ;  we  therefore  refer  to  the  sec- 
tion on  the  therapy  of  intestinal  cancer.  Occasionally  special  symp- 
toms (e.  g.,  diarrhoea)  require  treatment  other  than  that  given  under 
cancer. 

As  shown  by  the  observations  of  MicheP^,  Gilford*^,  Hahn^, 
Engstrom™,  and  others,  surgical  treatment  may  at  times  be  suc- 
cessful, even  though  the  sarcoma  be  situated  in  the  upper  seg- 
ments of  the  intestinal  canal.  Favourable  results  are,  however, 
much  more  frequent  in  sarcoma  of  the  rectum.  Recurrences 
generally  occur  sooner  and  more  extensively  than  in  intestinal 
cancer. 

Where  operation  is  contraindicated,  the  systematic  subcutaneous 
injections  of  arsenic,  according  to  the  method  of  von  Ziemssen'^^, 
have  given  favourable  results  both  upon  the  symptoms  and  the 
general  condition  of  the  patient. 

B.    BENIGN  NEOPLASMS  OF  THE  INTESTINAL  CANAL 

Benign  tumours  of  the  intestine  are  extremely  rare.  Some 
possess  no  clinical  interest,  since  they  produce  no  symptoms  during 
life.  Others,  however,  are  of  greater  importance  from  a  diagnos- 
tic, therapeutic,  and  especially  from  a  prognostic  standpoint.  It 
thus  becomes  necessary  to  describe  these  tumours. 

Benign  intestinal  neoplasms  include  adenoma,  lipoma,  fibroma, 
myoma,  and  myxoma.  In  some  cases  we  have  mixed  tumours ; 
sometimes  there  are  combinations  of  malignant  and  benign  tumours 
(myosarcoma,  fibro-sarcoma,  myxosarcoma,  adeno-carcinoma,  etc.). 

I.    Adenomata  and    Polypi 

The  adenomata  generally  originate  in  the  glands  of  Lieberkühn 
and  have  a  glandular  structure.  They  occur  on  the  mucous  mem- 
brane either  as  sessile  or  pedunculated  growths  (polypi) ;  they  may 
be  either  isolated  or  multiple ;  their  size  varies  from  that  of  a  pea 
to  a  fist.     They  are  found  in  all  parts  of  the  intestinal  canal,  but 


334  DISEASES  OF  THE  INTESTINES 

their  favourite  seat  is  tlie  rectum.  They  occur  at  different  ages, 
but  the  first  years  of  Hfe  contribute  by  far  the  largest  number 
of  examples.  In  some  cases  these  polypi  are  the  starting  points 
for  the  development  of  malignant  growths  (sarcoma  and  cancer). 
Their  transition  into  tuberculosis  has  been  described  by  Prochow- 
nick'''^. 

Multiple  polypi  of  the  rectum  and  large  intestine  present  a  par- 
ticularly important  type  of  adenomata.  According  to  the  observa- 
tions of  Luschka '^  Whitehead ^^  Häuser '^  Schwab''«,  Port"",  Holt- 
mann"^,  and  others,  they  form  tumours  of  various  sizes  which  some- 
times extend  along  the  entire  length  of  the  large  intestine  from 
the  rectum  to  the  iieo-csecal  valve.  Häuser  and  Port  have  shown 
that  they  may  even  extend  into  the  small  intestine  and  the  pyloric 
orifice  of  the  stomach.  The  interest  in  these  cases  lies  particularly 
in  the  severe  bleedings  which  they  cause,  and  in  their  tendency  to 
carcinomatous  degeneration  (Helferich — Port"",  Bardenheuer ''^^, 
Smith ^°,  Handford  ^^,  Paget  ^^,  Hutchinson  ^^,  Makins^^,  Häuser ''^, 
Holtmann  ''^).  A  very  striking  fact  is  a  certain  hereditary  predispo- 
sition, which  was  observed  in  no  less  than  4  of  the  13  cases  gathered 
by  Port.  In  view  of  the  relatively  small  number  of  these  cases, 
I  deem  it  proper  to  report  one  which  I  had  under  observation 
several  years  ago. 

Polyposis  recti  et  coli  ;  partial  extirpation  of  the  polypoid  masses  ;  death  from 
peritonitis. 

Mrs.  P.  G.,  age  36,  working  woman.  As  a  girl  the  patient  suffered  from 
malaria,  pneumonia,  and  pleurisy.  Has  had.  five  children  ;  severe  metrorrha- 
gia with  the  last.  The  beginning  of  the  present  illness  dates  back  seven  or  eight 
years.  She  then  complained  of  marked  tenesmus,  and  even  then  the  stools 
were  always  bloody.  These  symptoms  ceased,  for  months,  during  which  time 
she  felt  well.  The  periods  of  remission  became  shorter  from  year  to  year,  and 
latterly  her  symptoms  have  remained  constant. 

Patient  has  about  20  evacuations  a  day,  which  are  passed  as  follows  :  First, 
"bloody  water"  with  mucus  is  passed  ;  then  normal,  thin,  or  semisolid  faeces  ; 
finally,  often  a  large  quantity  of  blood  mixed  with  mucus.  At  times  there  are 
absolutely  no  faeces  in  the  evacuations.  For  several  years,  at  the  end  of  each 
evacuation  a  nodule  was  protruded  from  the  anus  ;  this  finally  fell  off  ;  it 
looked  "as  if  composed  of  small  growths."  After  this  patient  felt  better 
for  a  few  days,  except  for  the  tenesmus  and  the  hemorrhages.  The  general 
condition  of  the  patient  is  only  very  slightly  disturbed. 

Status  Prmsens. — Anaemic  woman ;  normal  circulatory  and  respiratory  organs ; 
ptosis  and  atony  of  the  stomach  ;  displaced  right  kidney  ;  no  other  abdominal 
irregularity  on  palpation  ;  intestines  not  sensitive  to  pressure.  On  rectal 
examination  there  were  found  grapelike  masses  as  large  as  peas  or  beans,  which 


INTESTINAL   NEOPLASMS 


335 


consisted  of  broad-based  excrescences  ;  about  20  of  these  were  easily  removed 
by  the  examining  finger.  After  rectal  lavage,  blood  and  several  pea-sized 
polypi  were  found  in  the  wash  water.  Microscojiical  examination  shows  dis- 
tinct adenomatous  structure.  Upon  severe  straining  a  deep-red  tumour,  about 
the  size  of  an  ostrich  egg,  protruded  itself.  It  consisted  of  numerous  large 
and  small  polypi,  and  of  several  hemorrhoidal  nodules. 

Since  extirpation  (see  Fig.  30)  of  the  rectum  seemed  impossible,  the  mass 
was  partially  removed  on  July  35,  1893.  During  the  operation  the  peritoneum 
was  opened.  Death  from  peritonitis  three  days  later.  Autopsy  showed  that 
the  entire  length  of  the  large  intestine  was  carpeted,  as  it  were,  with  innu- 
merable large  and  small  polypi. 

Adenomata,  particularly  of  the  rectum,  are  easily  diagnosti- 
cated, especially,  when  the  protrusion  of  one  or  two  polypi,  as  so 
frequently  happens,  allows  of  a  direct 
macroscopic  and  microscopic  examina- 
tion. 

Of  the  siibjeGtive  symptoms  hemor- 
rhage and  tenesmus  particularly  neces- 
sitate a  digital  examination.  If  the 
patient  strains  during  such  examina- 
tion, the  finger  may  draw  down  a  sin- 
gle or  more  often  multiple  polypi  out 
of  the  anus ;  these  may  then  be  care- 
fully tied  and  cut  oif  and  their  struc- 
ture immediately  studied. 

Even  when  the  tumours  are  situated 
higher  up,  their  recognition  is  not  very 
diflScult ;  the  soft  consistency,  the  well- 
defined  limits,  the  pedicle,  the  absence 
of  ulcerations,  particularly  the  sharp 
localization  of  the  process,  are  unmis- 
takable. However,  the  fact  that  ma- 
lignant processes  may  develop  upon  the 
bases  of  such  polypoid  growths,  of 
which  I  myself  have  observed  two  in- 
stances, must  warn  the  physician  to  be  guarded  in  the  prognosis 
If  multiple  rectal  polypi  are  present  we  must  suspect  further  exten 
sion  of  the  growths  into  the  intestinal  canal. 


Fig.  30. — Multiple  Polypi  of  the 
Eectum.     (Personal  observation.) 


II.    Lipoma,  Myoma 

Lipoma  is  more  frequent  than  myoma.     There  are  scarcely  two 
dozen  clinically  observed  cases  of  myoma,  but  since  the  advance  of 


336  DISEASES   OP  THE  INTESTINES 

surgery  the  eases  of  intestinal  myoma  reported  seem  to  have  mate- 
rially increased.  The  remaining  benign  intestinal  tumours  (angi- 
oma, myxoma,  teratoma,  and  others)  possess  as  yet  no  clinical  sig- 
nificance. 

Lipomata  generally  originate  in  the  submucosa,  their  most  fre- 
quent seat  being  the  large  intestine  and  rectum.  Their  size  varies 
considerably ;  generally,  however,  they  are  of  an  appreciable  size 
(up  to  that  of  a  child's  head).  They  occur  either  isolated  or  mul- 
tiple. The  diagnosis  of  lipoma  is  only  possible  vt^hen  they  are  situ- 
ated in  the  rectum  and  produce  symptoms.  In  other  cases  where 
no  tumour  is  felt  either  by  vaginal  or  abdominal  examination,  a 
definite  diagnosis  is  impossible.  Occasionally  expulsion  of  the 
lipoma  (Castelain^,  Albrecht^,  Link^,  Paci^^,  etc.)  has  revealed 
the  cause  of  the  symptoms. 

Myomata  of  the  intestinal  canal  arise  partly  from  the  mucosa 
and  submucosa,  partly  from  the  subserosa.  Following  Yirchow, 
those  from  the  mucosa  and  submucosa  are  known  as  internal,  and 
those  from  the  subserosa  as  external  myomata.  Steiner  ^"^^  who  has 
made  an  exhaustive  analysis  of  benign  neoplasms  of  the  gastro- 
intestinal canal,  reported  19  cases  of  internal  and  15  of  external 
myomata.  The  tumour  is  usually  situated  in  the  small  intestine, 
and  only  exceptionally  in  the  large  intestine  (inclusive  of  the  rec- 
tum). The  duodenum  is  very  rarely  affected.  Myomata  vary 
very  much  in  size ;  they  may  be  as  small  as  cherries  or  as  large  as 
a  man's  head.  As  regards  the  age  at  which  myomata  may  occur, 
they  are  by  no  means  limited  to  young  individuals ;  cases  have 
been  reported  in  persons  forty,  fifty,  and  even  eighty  years  of  age. 

Only  when  there  is  a  definite  tumour  can  the  symptomatology 
and  diagnosis  of  myomata  be  considered.  Such  palpable  tumours 
are  found  in  but  a  limited  number  of  cases,  but  even  then  the 
diagnosis  will  be  made  in  very  exceptional  instances.  The  diagnosis 
will  be  possible  in  internal  myomata,  when  certain  complemental 
symptoms  or  complications  which  tend  to  clear  up  the  clinical  pic- 
ture are  present.  Among  these  we  might  mention  the  develop- 
ment of  a  more  or  less  complete  invagination,  which,  according  to 
Steiner,  was  observed  no  less  than  Y  times  in  18  cases.  In  a  case  of 
this  nature  described  by  Fleiner  ^,  in  view  of  the  chronic  course  of 
the  disease,  of  the  variation  of  the  patient's  condition  from  good  to 
bad,  etc.,  the  diagnosis  of  myoma  was  made  with  a  fair  degree  of 
probability.  Besides  an  invagination,  the  gradual  development  of 
an  intestinal  stenosis  or  an  obstruction  is  of  great  diagnostic  signifi- 


INTESTINAL  NEOPLASMS  337 

cance ;  in  such  cases,  days,  weeks,  months,  or  even  years  of  abso- 
lutely good  health  may  intervene. 

The  symptoms  of  external  myoiriata  are  only  rarely  sharply 
defined.  Evidences  of  stenosis  may  be  present,  thus  making  the 
connection  between  the  neoplasm  and  the  intestinal  canal  more 
probable.  Complete  obstruction  by  kinking,  incarcerations,  or 
volvulus,  appears  to  be  still  more  infrequent.  In  several  in- 
stances the  intestinal  contents  were  bloody,  and  contained  nmch 
mucus.  Death  from  profuse  hemorrhages  from  the  bowel  has  also 
been  described. 

According  to  Steiner  ^^  the  following  data  indicate  external 
myomata  :  The  presence  of  a  slowly  growing,  intraperitoneal  (some- 
times also  retroperitoneal)  tumour,  hard  and  nodular  on  its  sur- 
face, and  having  no  connection  with  the  genital  organs ;  passive 
movements  of  this  tumour  cause  dragging  pain  in  the  abdomen  ; 
there  may  be  symptoms  of  an  obstruction  of  the  intestinal  lumen, 
and  finally  intestinal  hemorrhages. 

Despite  these  data  we  shall  hardly  be  able  to  diagnosticate  other 
than  the  presence  of  an  intestinal  neoplasm  of  unknown  nature. 

Myomata  of  the  rectum  require  a  brief  mention.  According 
to  Steiner,  only  6  cases  have  been  observed.  Here  also  we  dis- 
tinguish between  the  external  and  internal  myomata.  The  symp- 
tomatology of  the  former  is  quite  similar  to  that  of  pedunculated 
polypi — passing  of  blood  and  mucus,  tenesmus,  and,  when  of  large 
size,  evidences  of  rectal  stricture.  The  diagnosis  of  myoma  recti 
may  be  made  when  by  rectal  (and  vaginal)  examination  a  rather 
smooth,  movable  tumour,  with  a  more  or  less  thick  pedicle  attached 
to  the  mucous  membrane  is  felt. 

The  clinical  picture  of  external  rectal  myomata  is  much  less 
characteristic.  When  they  reach  considerable  size  they  compress 
the  pelvic  organs  and  become  adherent  to  the  latter.  The  only  re- 
maining diagnostic  data  are  the  occurrence  of  rectal  hemorrhages 
and  the  obstruction  to  evacuations.  It  would  also  be  of  diagnostic 
importance  to  demonstrate  that  the  tumour  is  not  connected  with 
the  genital  organs. 

Treatment 

ISTo  matter  in  what  portion  of  the  intestinal  canal  the  benign 
tumour  may  be  found,  internal  treatment  can  be  of  little  benefit. 
We  shall  have  to  limit  ourselves  to  the  treatment  of  the  symptoms 
— pain,  stenosis,  enterorrhagia,  etc. 


338  DISEASES  OF   THE   INTESTINES 

Expectant  treatment  may  be  successful,  for  benign  tumours, 
especially  when  situated  in  the  lower  intestinal  segments,  are  some- 
times spontaneously  expelled.  As  already  mentioned,  this  has  been 
observed  in  lipomata,  adenomata  (polypi),  and  myomata  (Pellizari^^, 
Heurteux  ^). 

Eegarding  simple  pedunculated  polypi  of  the  rectum,  their 
removal  is  easily  accomplished  with  the  scissors  or  the  galvano- 
cautery.  The  case  is  quite  different,  however,  with  larger  myom- 
ata of  the  intestinal  canal.  In  many  cases  we  shall  have  to  be 
content  with  palliative  treatment.  Should  dangerous  symptoms 
occur  (invagination,  complete  or  beginning  intestinal  obstruction, 
severe,  repeated  intestinal  hemorrhages),  operative  extirpation  of  the 
tumour  is  indicated.  Successful  operative  results  in  internal  my- 
omata have  been  reported  by  Fleiner,  Czerny,  Lockwood,  Albert, 
Rosi,  Fenger,  and  Holländer  ^^  External  myomata  have  also  been 
successfully  operated  on  (Wölfler,  Babes-lSTanu,  Kukula,  and  Kru- 
kenberg). 

Internal  rectal  myomata  offer  no  great  difficulties  to  surgical 
treatment,  for  ligation  of  the  pedicle  and  removal  of  the  tumour  is 
usually  sufficient.  The  treatment  of  external  myomata  of  the 
rectum  is  the  same  as  that  of  rectal  cancer.  Removal  of  the 
tumour  by  laparotomy  is  indicated  when  its  growth  extends  beyond 
the  small  pelvis.  Cure  resulted  in  3  out  of  4  cases  of  external  rec- 
tal myoma  (Berg,  Senn,  PfannenstieP^). 

General  intestinal  j)olyposis  is  not  favourable  either  for  internal 
or  surgical  treatment.  Our  therapeutic  aim  will  be  limited  to 
decreasing  the  hemorrhages  by  appropriate  internal  medication 
(ergotin,  hydrastin,  witch-hazel),  or  by  astringent  enemata  (fer- 
ripyrin,  tannin,  aceto-tartrate  of  aluminum).  Partial  extirpation 
of  the  growth  may  be  symptomatically  advantageous.  Thus,  in  a 
case  of  polyposis  of  the  jejunum  and  ileum  recently  reported  by 
von  Karajan^^,  complete  cure  resulted  from  extirpation  of  10  of  the 
largest  polypi.  In  a  case  reported  by  Sklif assowski  ^*,  the  forma- 
tion of  an  artificial  anus  seemed  to  have  been  followed  by  some 
benefit. 

LITERATURE 

1.  A.  Zemann.     Bibliothek  d.  medicin.  Wissenschaften  (Dräsche),  Bd.  iii,  H. 

1  u.  2,  S.  49. 

2.  G.  Heinaann.     Archiv  f.  klin.  Chirurgie,  1899,  Bd.  Ivii,  H.  4. 

3.  Berard,   Rokitansky.     Cited    from  Leube  in  v.  Ziemssen's  Handbook,   p. 

335,  vol.  vii,  Part  II,  second  edition. 


INTESTINAL  NEOPLASMS  339 

4.  P.    Rüpp.     lieber  den   Darmkrebs   mit   Ausschluss  d.    Mastdarmkrebses. 

Inaug.-Diss.,  Zürich,  1894,  S.  10. 

5.  Maydl.     Ueber  den  Darmkrebs.     Wien,  1883,  S.  10. 

6.  Nothnagel.     Darmerkrankungen,  S.  219. 

7.  Hausmann.     These  de  Paris,  1883. 

8.  Iversen.     Verhandl.  des  X.  internationalen  medicinischen  Conoresses   Ber- 

lin, 1891,  Bd.  iii,  S.  98. 

9.  Kraske.     Erfahrungen  über  den  Mastdarmkrebs.     Volkmann's  Sammlung 

klinischer  Vorträge,  1883,  1884,  1897,  S.  787. 

10.  Käst  u.  Baas.     Münch.  med.  Wochenschr.,  1888,  No.  4. 

11.  Rommeläre.     Journ.  de  med.,  de  Chirurgie,  et  de  pharmacie  de  Bruxelles, 

1883-1886. 

13.  Fr.  Müller.     Zeitschr.  f.  klin.  Medicin,  Bd.  xvi,  S.  146. 
18.  G.  Klemperer.     Berl.  klin.  Wochenschr.,  1889,  No.  40. 

14.  Schneyer.     Internat,  klinische  Rundschau,  1894,  No.  39. 

15.  F.  Henry.     Arch,  für  Verdauungskrankheiten,  1898,  Bd.  iv,  H.  1. 

16.  Czygan.     Ibid,  1897,  Bd.  iii,  S.  83. 

17.  Leichtenstern.     von  Ziemssen's  Handbuch,  1878,   Bd.  vii,  2,  3te  Aufl.,  S. 

418. 

18.  Herz.     Deutsche  med.  Wochenschr.,  1896,  No.  23  u.  24. 

19.  Gerhardi.     Virchow's  Archiv,  1886,  Bd.  cvi,  S.  303.     Inaug.-Diss.,  Zürich, 

1886. 

30.  Hagenbach.     Deutsche  Zeitschr.  f.  Chirurgie,  1887,  Bd.  xxvii,  H.  1  u.  3, 

S.  110. 

31.  Wilms.     Beiträge  zur  klin.  Chirurgie,  1897,  Bd.  xviii,  H.  3. 

32.  Weecke.     Inaug-Diss.,  Kiel,  1894. 

33.  Pic.     Revue  de  m6decine,  1894,  No.  13,  and  1895,  No.  1. 

34.  Bard  et  Pic.     Ibid.,  1888,  vol.  viii. 

35.  Lannois  et  Courmont.     Ibid.,  1894,  vol.  xiv. 

36.  Janicke.     Würzburger  Verhandlungen,  1877. 

27.  Kernig.     Petersburger  med.  Wochenschr.,  1881,  No.  4. 

38.  Oser.     Die  Erkrankungen  des  Pankreas,  Wien,  1898,  S.  314. 

39.  Miralliö.     Gaz.  des  hopitaux,  1893,  p.  889. 

30.  Treves.     Darmobstruction.     Uebersetzt  von  A.  Pollak,   1888.     [Intestinal 

Obstructions.     New  York,  1899.] 

31.  Potain.     Cited  from  Maydl,  Ueber  den  Darmkrebs,  1883,  S.  51. 
33.  Wunderlich.     Cited  from  Rüpp  (see  ref.  4). 

33.  Nicolaysen.     Cited  from  Maydl  (see  ref.  5). 

34.  Bamberger.    Krankheiten  des  Chylopoetischen  Systems.    Virchow's  Handb. 

d.  spec.  Pathologie  u.  Therapie,  Bd.  vi,  Würzburg,  1864. 

35.  Bamberger.     Zeitschr.  f.  prakt.  Heilkunde,  1857,  Bd.  iii. 

36.  Krausshold.     Ueber   Krankheiten  des  Proc.  vermiformes  u.  des  Coecums. 

Volkmann's  Sammlung  klin.  Vorträge,  No.  191. 

37.  Schede.     Cited  from  Paul  Wolff,  Ueber  Geschwülste  d.  Ileocoecalgegend. 

Inaug.-Diss.,  Berlin,  1893. 

38.  Richelot  u.  Hartmann.     Cited  from  Virchow-Hirsch's  Jahresbericht,  1894, 

Th.  ii,  S.  462. 

39.  von  Bergmann.     Deutsche  med.  Wochenschr.,  1895,  Vereinsbl.,  S.  54. 


340  DISEASES  OF  THE  INTESTINES 

40.  Hahn.     Berl.  klin.  Wochenschr.,  1887,  No.  25. 

41.  Czerny.     Beiträge  zur  klin.  Chirurgie,  Bd.  ix,  S.  797,  Fall  14. 

43.  von  Esmarch.     Cited  from  J.  Mockenhaupt.     Inaug. -Diss.,  Kiel,  1894. 

43.  Salzer.     Arch.  f.  klin.  Chirurgie,  Bd.  xliii,  S.  149. 

44.  Pässler.     Berl.  klin.  Wochenschr.,  1895,  No.  34. 

45.  Israel.     Ibid.,  1894,  No.  11. 

46.  Hochenegg.     Wiener  klin.  Wochenschr.,  1897,  No.  33. 

47.  Wölfler.     Berl.  klin.  Wochenschr.,  1896,  No.  34. 

48.  Billroth.     Verhandlungen  des   X.    internationalen  Congresses  zu  Berlin, 

1891,  Bd.  iii,  Abth.  7,  S.  76  u.  f. 

49.  Czerny.     XII.  Chirurgencongress,  1893. 

50.  Nicolaysen.     Cited  from  Rüpp  (see  ref.  4). 

51.  Hochenegg.     Wiener    klin.    Wochenschr.,    1888,    No.    14-16,    1889,    No. 

36-30. 

52.  von  Heinecke.     Münch.  med.  Wochenschr.,  1888,  No.  35. 

53.  W.  Levy.     Centralbl.  f.  Chirurgie,  1889,  No.  13. 

54.  Schlange.     Berl.  klm.  Wochenschr.,  1893,  No.  47. 

55.  Liermann.     Beiträge  zur  klin.  Chirurgie,  Bd.  xix,  H.  3,  and  Arch.  f.  klin. 

Chirurgie,  Bd.  iviii,  H.  3. 

56.  Lövinsohn.     Beiträge  zur  klin.  Chirurgie,  Bd.  x,  S.  308.    Lobstein.    Berl. 

klin.  Wochenschr.,  1897,  No.  30  u.  31. 

57.  Czerny.     Berl.  klin.  Wochenschr.,  1897,  No.  36. 

58.  Kundrat.     Wiener  klin.  Wochenschr.,  1893,  No.  13. 

59.  Fr.  Krüger.     Inaug. -Diss.,  Berlin,   1894. 

60.  Baltzer.     Arch.  f.  klin.  Chirurgie,  Bd.  xliv,  H.  4. 

61.  Madelung.     Centralbl.  f.  Chirurgie,  1893,  No.  30. 
63.  Bessel-Hagen.     Virchow's  Archiv,  Bd.  xcix,  S.  99. 

63.  Müller.     Inaug. -Diss. ,  Zurich,  1894. 

64.  W.  Claus.     Inaug. -Diss.,  1888. 

65.  Ricker.     Arch.  f.  klin.  Chirurgie,  1895,  Bd.  1. 

66.  Dietrich.     Beiträge  zur  klin.  Chirurgie,  1896,  S.  377. 

67.  Rud.  Schmidt.     Wiener  klin.  Wochenschr.,  1898,  No.  21. 

68.  Michel.     Inaug.-Diss.,  Würzburg,  1889. 

69.  Gilford.     The  Lancet,  1889,  1893. 

70.  Engström.     Cited  from  Arch.  f.  Verdauungskrankheiten,  vol.  iv,  p.  219. 

71.  von  Ziemssen.     Deutsches  Arch.  f.  klin.  Medicin,  1895,  Bd.  Ivi,  H.  1  u.  2, 

S.  134. 
73.  Prochownick.     Münch.  med.  Wochenschr.,  1896,  No.  49. 

73.  Luschka.     Virchow's  Archiv,  Bd.  xx,  S.  133. 

74.  Whitehead.     Brit.  Med.  Journal,  p.  410,  1884. 

75.  Hauser.     Deutsches    Arch.    f.    klin.    Medicin,    Bd.   Iv,    S.   429,    and    Das 

Cylinderepithelcarcinom   d.   Magens   u.    d.    Dickdarms,    Jena,   1890,   S. 
182  u.  191. 

76.  Schwab.     Beiträge  zur  klin.  Chirurgie,  Bd.  xviii. 

77.  Port.     Zeitschr.  f.  Chirurgie,  Bd.  xlii,  H.  1  u.  3. 

78.  Holtmann.     Multiple  Polypen  des  Colon  mit  Gallertkrebs.     Inaug.-Diss., 

Kiel,  1895. 

79.  Bardenheuer.     Arch.  f.  klin.  Chirurgie,  Bd.  xli,  H.  4. 


INTESTINAL  NEOPLASMS 


341 


'80.  Smith.     St.  Barthol.  Hosp.  Rep.,  vol.  xxiii,  1887. 

•81.  Handford.     Transact,  of  the  Pathol.  Soc.  of  London,  vol.  xli,  1890. 

82.  Paget,  Hutchison,  and  Makius.     Cited  from  Port  (see  ref.  77j. 

83.  Castelain.     Gaz.  hebdom.  de  medecine  et  de  Chirurg.,  1870,  No.  30. 

84.  Albrecht.     St.  Petersburger  med.  Wochenschr.,  1880,  No.  9. 

85.  Link.     Wiener  klin.  Wochenschr.,  1882,  S.  247. 

■86.  Paci.  Le  Sperimentale,  1882,  p.  46.  (Cited  from  Virchow-Hirsch's  Jahres- 
bericht, 1882.) 

87.  Steiner.  Beiträge  zur  klin.  Chirurgie,  1898,  Bd.  xxii,  H.  1  u.  2.  (Here 
will  be  found  extensive  literary  references.) 

:88.  Fleiner.     Virchow's  Archiv,  1885,  Bd.  ci,  S.  484  u.  f. 

89.  Pellizari.     Societa    medico-fisica   florentina,    1874.     (Cited   from    Steiner 

ref.  87.)  ' 

90.  Heurteux.     Gaz.  medic,  de  Nantes,  1884,  p.  135.     (Cited  from  Steiner,  ref 

87.) 

91.  Holländer.     Cited  from  Steiner  (ref.  87). 

'93.  Pfannenstiel.     Allgemeine  medicin.     Centralzeitung,  1897,  S.  56. 
«3.  von  Karajan.     Wiener  klin.  Wochenschr.,  1899,  No.  6. 
M.  Sklifassowski.     Wratsch,  1881,  No.  4.     (Cited  from  Centralbl.  f.  Chirurgie 
1881,  S.  527.) 


23 


CHAPTEE  XYIII 

INTESTINAL  STENOSIS  AND  INTESTINAL    OBSTRUCTION 

{ILEUS) 

A.     INTESTINAL  STENOSIS 

'  Preliminary  HemarTcs. — Of  all  disturbances  of  the  intestinal 
canal,  the  most  serious  are  those  which  interfere  with  the  normal 
passage  of  the  fseces.  Where  they  do  not  directly  threaten  life, 
such  disturbances  cause  a  number  of  extremely  distressing  sym.ptoms, 
which,  unless  relieved,  gradually  undermine  the  constitution  of  the 
patient  and  finally  produce  death.  At  first,  the  variety  and  situa- 
tion of  the  obstruction  seem  of  secondary  importance  to  the  dan- 
gers arising  therefrom  ;  for,  with  the  single  exception  of  faecal 
impaction,  the  danger  in  all  varieties  of  intestinal  obstruction  is 
practically  the  same.  It  would  thus  seem  that  the  trouble  taken 
in  the  study  and  classification  of  the  various  forms  of  intestinal 
obstruction  has  but  little  practical  value.  A  more  detailed  knowl- 
edge and  more  careful  study  will  show  that  this  idea  is  incorrect. 
The  clinical  features  of  intestinal  obstruction  are  never  the  same, 
and  the  recognition  of  the  differences  in  different  cases  is  im- 
portant for  diagnostic,  prognostic,  and  therapeutic  purposes,  par- 
ticularly in  surgery.  There  are  only  a  few,  though  perhaps  very 
important,  varieties  of  intestinal  obstruction  which  really  offer  in- 
surmountable diagnostic  difficulties. 

In  every  case  of  intestinal  obstruction  the  following  facts  must 
be  determined  before  a  diagnosis  can  be  arrived  at : 

1.  First  and  most  important,  the  establishment  of  the  presence 
of  intestinal  obstruction  or  stenosis. 

2.  Determination  of  its  situation. 

3.  Determination  of  its  anatomical  causes. 

In  order  to  understand  the  symptoms  of  individual  cases,  and  in 
view  of  the  practical  purpose  of  this  work,  it  appears  to  me  prefer- 
able to  first  give  the  general  symptomatology  of  intestinal  strictures 
and  occlusions,  and  then  the  symptomatology  and  diagnosis  of  the 
several  kinds  of  obstruction.  The  differential  diagnosis  will  be 
342 


INTESTINAL  STENOSIS  343 

treated  of  in  a  separate  section,  and,  finally,  the  treatment  of  all 
forms  will  be  discussed  together.  Owing  to  their  extreme  rarity 
and  because  of  their  lack  of  practical  clinical  significance,  congenital 
stenosis  and  occlusion  will  be  left  entirely  out  of  consideration. 
Stenoses  of  the  rectum  are  described  in  the  chapter  on  Diseases  of 
the  Rectum. 

General  Symptomatology  of  Stricture  of  the  Intestine 

The  idea  embodied  in  the  term  "  intestinal  stricture "  already 
seems  to  imply  a  gradual  development  with  well-defined  symptoms 
only  in  advanced  stages  of  the  disease.  Patients,  as  a  rule,  complain 
of  the  characteristic  symptoms  of  stricture  only  when  the  process  is 
relatively  far  advanced.  There  are,  however,  important  exceptions 
to  the  usual  course.  In  the  first  place,  a  chronic  stricture  may  de- 
velop shortly  after  a  complete  obstruction  (pseudo-ligaments,  hernial 
orifices,  partial  obstruction  by  gallstones,  foreign  bodies,  intestinal 
concretions,  intussusception,  compression)  (Leichtenstern  ^).  On  the 
other  hand,  the  characteristic  picture  of  chronic  intestinal  stenosis 
may  for  a  time  be  present ;  then,  either  through  muscular  paralysis, 
marked  increase  of  the  stricture,  or  through  impaction  of  foreign 
bodies  (generally  undigested  food),  the  chronic  stenosis  suddenly 
changes  into  a  complete  intestinal  obstruction.  In  other  cases, 
again,  the  change  is  less  acute.  For  example,  a  patient  has  passed 
through  several  attacks  of  intestinal  stenosis,  each  one  more  severe 
than  the  preceding  one,  so  that  it  is  probable  that  the  next  attack 
will  be  one  of  complete  obstruction. 

The  clinical  picture  varies  in  accordance  with  the  site  and  de- 
gree of  the  stenosis. 

Regarding  the  site,  we  may,  in  general,  differentiate  between 
strictures  of  the  upper  and  of  the  lower  segments  of  the  intestines, 
the  former  including  the  portions  from  below  the  pylorus  to  the 
jejunum  inclusive,  the  latter  those  from  the  ileum  to  the  rectum. 
Both  have  this  in  common,  that  the  normal  onward  movement  of  the 
bowel  contents  is  either  delayed  or  entirely  interfered  with.  As 
a  natural  result  a  dilatation  gradually  develops  above  the  stenosis, 
and  acts  as  a  reservoir  for  the  retained  fluid  or  solid  masses.  It 
is  quite  evident  that  this  will  occur  to  a  lesser  degree  in  stenoses 
above  the  jejunum  than  in  those  lower  down.  It  is  clear  that  the 
latter  variety  demands  considerably  greater  expulsive  power  of  the 
intestinal  muscles  than  does  the  former.  Finally,  in  deep-seated 
stenoses  the  recoil  contraction  can  have  little  effect  in  causinö;  a 


344  DISEASES  OF  THE  INTESTINES 

backward  movement  of  the  solid  matters  in  tlie  intestine ;  in  ste- 
noses of  the  upper  bowel,  however,  where  the  contents  are  fluid, 
very  little  force  is  required  for  their  regurgitation. 

From  these  differences  the  chief  symptomatological  distinctions 
between  the  two  types  arise. 

Let  us  begin  with  the  small  intestine.  In  general  the  symp- 
toms point  rather  to  disturbances  of  gastric  than  of  intestinal  func- 
tions. The  subjective  symptoms  are  those  of  chronic  overdisten- 
tion  of  the  stomach  from  the  backward  pressure  of  the  retained 
duodenal  and  jejunal  contents — viz.,  fulness,  pressure,  pains,  eruc- 
tation, nausea,  vomiting. 

iSTaturally  this  permanent  stasis  is  not  without  its  effect  upon 
the  appetite  and  nutrition — both  of  these  suffer  more  or  less.  The 
increasing  vomiting  will  also  affect  or  retard  the  evacuations,  but 
not  nearly  as  much  as  in  stenosis  of  the  lower  intestinal  segments. 
In  general,  meteorism  is  very  moderate  and  limited  to  the  epigas- 
trium. In  marked  stenosis  the  fluid  chyme  can  pass  downward 
through  the  intestinal  canal,  or  flnd  its  way  upward  to  the  stom- 
ach ;  therefore  in  stenoses  of  the  upper  part  of  the  intestines,  intes- 
tinal peristalsis,  or  intestinal  rigidity  is  rarely  seen.  For  the  same 
reason  severe  paroxysms  of  pain  are  also  absent. 

The  clinical  picture  of  deeply  situated  intestinal  stenosis,  par- 
ticularly that  of  the  large  intestine.,  is  quite  different.  Here  the 
evidences  of  muscular  insufiiciency  become  very  prominent.  In 
the  flrst  place  there  is  constipation,  which  may  be  the  only  symp- 
tom in  the  beginning,  or  throughout  the  disease.  But  constipation 
in  itself  allows  us  to  draw  no  conclusion  respecting  the  ominous 
changes  occurring  within  the  intestinal  lumen.  Even  this  symp- 
tom is  sometimes  absent.  ISTothnagel  ^  cites  a  case  of  cancer  of  the 
sigmoid  flexure  in  which  natural  firm  evacuations  occurred  one  day 
before  complete  intestinal  occlusion  set  in ;  and  every  experienced 
physician  can  cite  similar  instances.  Although  constipation  is  one 
of  the  most  frequent  symptoms  of  stenosis  of  the  large  intestine, 
we  may,  as  in  intestinal  cancer  (page  311),  occasionally  have  the 
reverse  condition,  namely,  diarrhoea.  The  latter  is  caused  either  by 
decomposition  of  the  dejecta  above  the  stricture,  or  by  irritation  of 
intestinal  ulcers  (stercoraceous  ulcers,  distention  ulcers  (Kocher)). 
Finally,  constipation  may  alternate  with  diarrhoea. 

In  connection  with  obstinate  constipation,  spasmodic  pains  may 
sooner  or  later  develop.  These  pains  are  distinguished  from  those 
of  ordinary  flatulent  colic  by  their  frequent  recurrence  and  in- 


INTESTINAL  STENOSIS  345 

creased  duration  and  intensity.  At  a  late  stage  they  may  be  con- 
tinuous. 

In  contrast  to  flatulent  colic,  in  which  th«  whole  or  greater  part 
of  the  abdomen  is  tympanitically  distended,  the  meteorism  even  in 
advanced  stenosis  of  the  large  intestine  is  generally  inconsiderable. 
Only  after  complete  obstruction  with  intestinal  paralysis,  do  general 
meteorism  and  simultaneous  cessation  of  intestinal  contractions  occur. 
When  we  consider  that  the  gases  developed  by  the  accumulated  in- 
testinal contents  are  powerful  stimuli  to  peristalsis,  it  is  not  difiicult 
to  understand  why  meteorism  is  absent  as  long  as  the  functional 
activity  of  the  bowel  is  preserved. 

The  most  important  accompanying  symptom  of  painful  intes- 
tinal contraction  is  the  occurrence  of  msihle,  spasmodic  intestinal 
peristalsis^  a  phenomenon  which  Nothnagel^  appropriately  called 
"intestinal  rigidity."  These  severe  visible  and  palpable  spasmodic 
contractions  of  the  intestines  in  their  effort  to  force  their  con- 
tents through  the  stricture,  are  analogous  to  the  attempt  of  the 
uterus  to  force  the  child's  head  through  the  relatively  small  out- 
let by  increased  muscular  action.  This  intestinal  contraction  is  a 
favourable  symptom  in  so  far  as  it  proves  that  the  hypertrophied 
intestinal  muscle  still  possesses  a  certain  amount  of  power ;  on  the 
other  hand,  it  demonstrates  that  the  stenosis  is  so  great  that  extraor- 
dinary efforts  are  necessary  in  order  to  pass  the  obstruction. 

In  the  General  Division  (page  69)  we  have  already  discussed  the 
phenomena  of  intestinal  rigidity.  We  shall  return  to  its  significance 
and  varieties  in  the  section  on  diagnosis. 

Formerly  great  value  was  laid  upon  the  consistency  of  the  stools. 
It  was  believed  that  pointed,  narrow- calibred  stools  were  char- 
acteristic of  stenosis  of  the  large  intestine.  This  error  has  found 
its  way  even  among  the  laity,  and  every  physician  can  cite  cases  of 
imaginary  stenosis  in  which  the  patients  complain  of  constipation 
and  habitually  examine  their  own  stools.  Laparotomy  has  been 
performed  in  a  number  of  these  patients. 

We  now  know  that  in  intestinal  stenosis  the  stools  have  no 
characteristic  appearance,  for  we  find  similar  stools  in  spasmodic 
constipation,  intestinal  atrophy,  in  membranous  enteritis,  and  even 
in  ordinary  intestinal  catarrh.  It  appears  to  me  that  the  idea  of 
so-called  stenotic  dejections  has  originated  in  great  part  from  stric- 
tures of  the  lower  large  intestine  (from  the  sigmoid  downward),  for 
in  that  part  of  the  tract  characteristic  stools  do  actually  occur. 
Under  certain  conditions,  blood,  pus,  and  mucus  may  be  mingled 


346  DISEASES   OF   THE   INTESTi:^rES 

with  the  evacuations.  These  anomahes,  however,  are  not  peculiar 
to  the  clinical  picture  of  intestinal  stenosis  as  such,  but  depend 
upon  the  underlying  intestinal  disease. 

Special  Symptoms  and  Diagnosis  of  Intestinal  Stenosis 

In  well-marked  cases  the  diagnosis  of  intestinal  stenosis  is  easy ; 
in  other  cases  only  a  probable  diagnosis  can  be  made;  in  some 
the  diagnosis  is  impossible.  This  depends  partly  upon  the  site  of 
the  occlusion  and  partly  upon  the  prominence  of  the  symptoms, 
which  vary  in  the  different  kinds  of  stenosis. 

{a)  Stenosis  of  the  Small  Intestine 

Analogous  to  the  classification  of  malignant  disease  of  the  small 
intestine,  benign  stenoses  are  also  divided  into  the  suprapapillary 
and  infrapapillary,  jejunal,  and  ileal  forrns.  As  already  stated  in 
the  chapter  on  Intestinal  Cancer  (page  303),  the  diagnosis  of  supra- 
papillary  stenosis  is  rarely  possible.  Its  clinical  picture  is  so  similar 
to  that  of  pyloric  stricture,  that,  despite  the  most  careful  examina- 
tion, a  correct  diagnosis  is  the  exception  and  a  false  diagnosis  the 
rule.  The  diagnosis  can  be  made  with  a  fair  degree  of  probability 
only  when  the  subjective  symptoms  point  to  the  duodenum  as  the 
certain  site  of  the  lesion.  In  the  following  case  the  diagnosis  was 
made  with  the  greatest  possible  clinical  certainty  before  operation. 

Stenosis  of  the  sujjerior  i^ortion  of  the  duodenum  follotcing  an  incarcerated 
gallstone.     Tetany.      Gastro-enterostomy .     Death. 

Mrs.  N.,  fifty  years  old,  has  been  suffering  from  attacks  of  gastric  colic  for 
over  twenty  years.  These  would  often  cease  for  years,  and  later  return  accom- 
panied by  very  intense  pain.  The  attacks  lasted  minutes  to.  hours,  and  were 
frequently  accompanied  by  chills,  fever,  cold  sweats,  and  vomiting.  Twenty 
years  ago  had  jaundice  and  clay-coloured  stools.  She  cannot  remember  wheth- 
er this  occurred  in  an  attack  of  colic  or  not. 

Patient  has  been  free  from  attacks  for  the  last  eight  years,  and  felt  well  till 
Christmas,  1897.  She  then  began  to  have  a  feeling  of  discomfort  in  the  epigas- 
trium, and  foul-smelling  eructations,  generally  toward  evening  ;  of  late  there 
have  been  acid  burning  eructations  early  in  the  morning,  and  regurgitation  of 
stomach  contents.  Since  the  end  of  January  there  has  also  been  vomiting  of 
large  quantities  of  fluid,  foul-smelling  masses,  but  not  of  blood.  Patient  often 
has  the  feeling  as  if  the  stomach  "  works  strongly  "  after  meals.  Always  re- 
lieved after  vomiting.  Marked  loss  of  weight ;  appetite  good ;  constipation 
obstinate. 

Status  Prcesens. — No  evidence  of  cachexia;  skin  of  yellowish  colour.  Slight 
emphysema;  heart  sounds  normal. 


INTESTINAL  STENOSIS  347 

Abdomen. — Abdominal  walls  are  moderately  fatty;  no  visible  gastric  or  in- 
testinal peristalsis.  When  the  stomach  is  empty  loud  splashing  and  succussion 
sounds  are  present  to  almost  a  handbreadth  below  the  umbilicus.  Epigas- 
trium not  sensitive  to  pressure;  no  pathological  dulness  or  resistance.  The 
border  of  the  liver  indistinctly  palpable  ;  hepatic  dulness  diminished,  and 
begins  at  mammary  line  at  upper  border  of  the  fourth  rib.  Spleen  and  kid- 
neys negative. 

The  vomitus  consists  of  undigested  food  remnants,  is  neutral  in  reaction, 
contains  large  quantities  of  sarcinse,  yeast  fungi,  muscle  shreds,  fat,  starch, 
stearic  acid  bundles.     No  long  bacilli. 

During  the  next  few  days  the  stomach  contents  were  expressed  during  the 
fasting  condition.  Each  time  food  remnants  rich  in  HCl,  and  showing  micro- 
scopically the  above-mentioned  substances,  were  obtained.  The  stools  consisted 
•of  scybala,  containing  enormous  numbers  of  fatty  acid  crystals.  The  quantity 
of  urine  was  between  400  and  900  centimetres  in  twenty-four  hours,  and  con- 
tained an  abundance  of  indican.     Otherwise  it  was  normal. 

Treatment. — Fluid  and  semisolid  diet.  Daily  gastric  lavage  ;  nutrient 
enemata. 

Course. — On  March  17th,  after  comjilaining  of  nausea  and  a  feeling  of 
abdominal  distention,  the  patient  suddenly  had  a  spasmodic  attack  limited  ex- 
clusively to  both  hands.  The  fingers  were  flexed,  but  could  be  passively 
extended.  Patient  was  collapsed ;  pulse  could  not  be  felt ;  face  cyanotic ;  eyes 
staring  and  glassy;  complete  consciousness  retained  throughout  the  attack, 
which  lasted  for  half  an  hour. 

Two  hours  later,  despite  repeated  examinations,  neither  Trousseau's  nor 
Chvostek's  phenomena  could  be  elicited.  There  was  no  muscular  irritability, 
no  sensory  disturbances.     Repeated  examinations  always  gave  the  same  results. 

On  March  20th,  after  previous  nausea  and  abdominal  pressure,  there  was 
numbness  and  stiffness  of  the  fingers. 

Since  the  stomach  contents  always  increased,  and  renewed  attacks  of  tetany 
were  feared,  the  patient  was  transferred  to  the  private  clinic  of  Professor  Hahn 
on  March  28th.     • 

The  probable  diagnosis  was  duodenal  stenosis,  situated  high  up,  consequent 
upon  incarcerated  gallstones. 

Operation  on  March  31,  1897,  by  Professor  Hahn.  Slight  attack  of  tetany 
during  narcosis. 

Laparoton).y . — The  pylorus  is  free;  underneath  it  is  felt  a  large  gallstone. 
In  order  to  reach  the  latter  a  horizontal  incision  is  made  in  the  region  of  the 
gall  bladder.  Gall  bladder  and  parts  about  the  gallstone  tightly  adherent  to 
the  duodenum.  The  gallstone  partly  compresses  the  duodenum  and  partly 
protrudes  into  its  lumen.  The  adhesions  are  separated  and  the  stone  lifted  out 
of  its  bed,  during  which  manipulation  the  duodenum  is  torn.  Intestinal 
suture,  then  gastro-enterostomy.  The  stone  is  composed  of  Cholesterin.  Col- 
lapse and  death  the  following  day. 

In  a  second  case — a  bookkeeper,  fifty  years  old — the  proba- 
Vie  diagnosis  of  bigh  duodenal  stricture  and  calculus,  resulting 
from    cbolelitbiasis   witb    icterus   wbich    bad    lasted   many   years, 


348  DISEASES   OF   THE   INTESTINES 

was  made.  Gastro-enterostomy  was  performed  hy  Dr.  Hahn  and 
the  diagnosis  was  confirmed.     The  patient  was  cured. 

These  two  cases  are  interesting  because  thej  show  that  the  sus- 
picion of  calculous  obstruction  of  the  pylorus  and  duodenum  may- 
be awakened  by  the  occurreuce  of  attacks  of  cholehthiasis  for  many 
rears,  and  by  the  later  occurrence  of  dilatation  of  the  stomach.  In 
view  of  the  close  relation  between  the  gall  bladder  and  duodenum, 
we  are  justified  in  suspecting  the  duodenum  as  the  site  of  the  ste- 
nosis. 

On  the  other  hand,  as  demonstrated  by  a  case  recently  described 
by  Wegele^,  the  diagnosis  of  a  high  calculous  duodenal  stenosis 
may  be  very  difficult  during  life,  and  even  during  the  course  of 
operation. 

The  diagnosis  of  low  (infrapapillary)  duodenal  stenosis  may  be^ 
made  with  a  much  greater  degree  of  probability.  This  has  been 
shown  by  the  more  recent  observations  of  Leichtenstem  ^,  Cahn\ 
EiegeP,  Hochhaus",  Schule^,  Reiche^,  Herz^'^,  Pic",  Eewidzoff^\ 
and  myself  ^^.  From  the  writings  of  the  authors  just  mentioned, 
the  following  may  be  considered  typical  symptoms  of  infrapapillary 
stenosis : 

The  most  important  subjective  symptoms  are  functional  dis- 
turbances of  the  stomach,  like  those  which  occur  in  gastrectasis — 
viz.,  diminished  appetite,  feeling  of  pressure  and  fulness,  or  even  of 
intense  pain  after  taking  food,  eructations,  nausea,  vomiting,  con- 
stipation, decreased  diuresis,  and  marked  loss  of  weight  and  strength. 
If  in  conjunction  with  these  symptoms  there  is  evidence  of  previous 
disease  of  the  duodenum  and  its  surroundings  (enterorrhagia,  duo- 
denal ulcer,  disease  of  the  pancreas,  gallstones,  cholecystitis,  cho- 
langitis, and  icterus),  we  must  suspect  disease  of  this  segment  of 
the  small  intestine.  If,  furthermore,  the  vomitus  is  constantly  bile 
tinged,  the  suspicion  becomes  a  probability,  and,  as  regards  the  site 
of  the  stricture,  a  certainty. 

The  objective  symptoms  chiefly  depend  upon  the  disturbed 
stomach  motility,  the  changes  in  the  gastric  secretion  being  of  sec- 
ondary importance.  The  stomach  may  be  of  normal  size  or  dilated 
(cases  of  Riegel,  Schule,  Herz,  and  others). 

Slight  visible  peristalsis  in  the  neighbourhood  of  the  pylorus 
may  be  present,  but  is  generally  absent  (Schule).  Meteorism,  is 
only  moderate  or  may  likewise  be  entirely  absent.  When  present, 
it  rapidly  disappears  through  the  eructations  and  the  vomiting 
(Leichtenstern  *,  Herz). 


INTESTINAL  STENOSIS  349 

The  constant  presence  of  hile  in  the  stomach  is  the  most  impor- 
tant evidence  of  infra  papillary  stenosis.  This  is  best  observed  in 
the  morning  after  the  stomach  had  been  washed  out  the  previous 
evening.  With  the  bile  the  duodenal  secretion  {succus  entericus 
and  pancreatic  juice)  is  forced  into  the  stomach,  and  thus  it  is  some- 
times possible  to  exclude  severe  disease  of  the  pancreas  by  the  pres- 
ence of  active  pancreatic  juice  (Boas).  That  under  diseased  con- 
ditions pancreatic  digestion  may  still  continue,  is  proved  by  a  case 
recently  reported  by  Wilms  ^*,  of  a  deeply  situated  duodenal  stenosis 
resulting  from  compression  of  a  pancreatic  cancer.  Pertinent  con- 
clusions can  only  be  drawn  when  the  digestive  tests  are  negative. 

In  these  cases  the  secretion  of  gastric  juice  depends  upon  the 
amount  of  regurgitated  duodenal  contents,  the  duration,  and  per- 
haps also  upon  the  nature  of  the  disease.  Varying  amounts  of 
HCl  have  been  found  in  the  different  kinds  of  stenosis  of  the 
descending  portion  of  the  duodenum.  According  to  Riegel's  and 
my  own  experience,  the  same  individual  may  at  one  time  have 
abundant  hydrochloric  acid  in  his  stomach,  and  at  other  times  none 
at  all.  As  I  have  demonstrated  ^^,  the  presence  of  bile  and  of  pan- 
creatic juice  interferes  with  the  digestive  properties  of  the  gastric 
juice  only  to  the  extent  that  the  latter  is  neutralized.  If  the  hydro- 
chloric acid  preponderates  in  the  mixture,  the  gastric  juice  has  t.s 
active  digestive  powers  as  in  the  normal.  On  the  other  hand,  in 
such  a  mixture,  even  though  it  be  made  alkaline,  the  pancreatic  fer- 
ments will  be  destroyed  (probably  due  to  the  acid). 

Microscopic  examination  may  show  evidences  of  gastric  fermen- 
tation (yeast,  sarcinse,  bacteria  of  various  kinds,  etc.) ;  it  may  also 
show  the  long  bacilli  generally  found  in  lactic  acid  fermentation. 

Discolouration  of  the  stools  and  increase  of  indican  in  the  urine 
(Boas)  are  of  diagnostic  significance.  Both  of  these  changes  may, 
however,  be  absent.  According  to  Herz,  bismuth  administered  l)y 
the  mouth  does  not  reappear  in  the  stool.  This  can  only  be  the 
case  in  very  marked  stenosis  of  the  lower  portion  of  the  large  intes- 
tine. In  connection  with  other  symptoms,  it  might  possess  diag- 
nostic value. 

If  palpable  changes  are  not  present  (tumour  of  the  duodenum 
or  of  its  surrounding  tissue,  adhesions,  etc.),  the  diagnosis  of  the 
underlying  cause  of  the  stenosis  is  very  difficult.  The  age  and  sex 
of  the  patient,  and,  as  already  mentioned,  the  clinical  history,  are  of 
value.  In  women  in  whom  there  is  a  history  of  frequent  attacks 
of  stomach  ache,  or  of  icterus,  we  must  suspect  impacted  stones, 


350  DISEASES  OF  THE  INTESTINES 

which  have  either  ulcerated  through  the  bile  duct  and  produced 
peritoneal  adhesions  with  the  duodenum  and  compression  of  the 
latter,  or  small  concretions  which  have  passed  through  the  common 
duct  into  the  lower  portion  of  the  duodenum,  and  produced  a  spas- 
tic obstruction  of  the  latter  (cases  of  Hochhaus,  Schule,  Herz,  and 
others). 

In  men  in  the  prime  of  life  we  must  think  of  duodenal  ulcera- 
tions as  the  cause  of  stenosis,  especially  if  the  characteristic  symp- 
toms of  this  disease  have  been  present.  Several  years  ago  I  observed 
and  reported  two  cases  of  ulcer  of  the  duodenum  with  resulting  ste- 
nosis of  the  descending  portion.  In  one  case,  which  I  shall  now 
describe,  the  autopsy  confirmed  the  diagnosis. 

Deeply  situated  duodenal  stenosis  following  cicatricial  contraction  from  duo- 
denal ulcer.      Gastro-enterostomy .     Death. 

Patient,  a  shoemaker,  says  that  since  early  childhood  he  has  suffered 
from  intestinal  disturbances  (diarrhoea,  anorexia,  occasional  biliary  vomiting), 
so  that  his  development  was  much  retarded.  In  his  seventeenth  year  he 
had  typhoid,  from  which  he  very  slowly  recovered.  He  felt  better  for  ä 
time,  but  frequently  thereafter  suffered  from  obstinate  vomiting,  with  diarrhoea. 
Certain  articles  of  food  were  said  to  be  passed  undigested.  The  patient  also 
complained  of  flatulence,  headaches,  inability  to  work,  and  lassitude. 

Examination  showed  a  poorly  nourished  man  with  normal  organs  of  respira- 
tion and  circulation.  Nothing  special  found  in  the  nervous  system.  The 
abdomen  is  somewhat  tympanitic,  but  no  new  growth  can  be  made  out;  liver 
and  spleen  normal;  kidneys  cannot  be  felt.  In  the  right  hypochondrium,  cor- 
responding to  a  prolongation  of  the  parasternal  line,  there  is  a  resistance,  which 
is  sensitive,  particularly  upon  deep  pressure.  The  limits  of  the  stomach  are  nor- 
mal. After  large  meals  slight  splashing  can  be  made  out  in  the  epigastrium. 
Distention  of  the  stomach  with  air  plainly  shows  the  larger  curvature  at  the 
level  of  the  umbilicus.  The  largest  diameter  obtained  by  extreme  distention 
is  13  centimetres.     Rectal  examination  and  insufflation  yield  nothing  special. 

The  examination  of  the  stomach  contents,  made  more  than  100  times  in 
three  years,  shows  the  permanent  presence  of  bile  and  the  absence  of  food 
remnants  during  fasting.  The  reaction  of  the  stomach  contents  was  at  first 
alkaline;  after  a  test  breakfast  they  were  occasionally  slightly  acid.  The  gas- 
tric contents,  both  in  the  fasting  condition  and  after  eating,  always  possessed 
peptic  power — i.  e.,  pancreatic  juice  was  mixed  with  the  bile.  Later  the  pic- 
ture changed;  the  gastric  contents  became  acid  and  gave  a  decided  hydro- 
chloric acid  reaction,  though  the  contents  were  still  bile-tinged.  After  some 
time  the  first-mentioned  condition  was  again  present.  There  was  again  dis- 
tinct HCl  reaction. 

The  patient's  condition  varied.  Diarrhoea  was  present.  At  times  the  pa- 
tient complained  constantly,  however,  of  a  painful  pressure  along  the  right 
parasternal  line,  lack  of  appetite,  headaches,  fatigue,  etc. 

Since  these  symptoms  recurred  during  the  following  months,  the  patient 


INTESTINAL  STENOSIS 


351 


consented  to  a  gastro-enterostomy ;  this  was  performed  in  January,  1892.  At 
the  laparotomy  the  pylorus  was  found  extremely  dilated,  so  that  it  was  very 
difficult  to  determine  which  was  the  duodenum  and  which  the  pylorus.  Exter- 
nally, besides  a  few  adhesions  of  the  duodenum  to  the  liver,  nothing  noteworthy 
was  discovered.     The  patient  died  the  following  day. 

Autopsy  showed  the  condition  of  the  stomach  and  duodenum 
pictured  below  (see  Fig.  31).  The  pyloric  ring  was  extraordinarily 
dilated,  and  toward  the  upper  portion  of  the  duodenum  almost 
obliterated.     The  first  portion  of  the  duodenum  was  also  extremely 


Pyloric  portion 
of  stomach 


Pyloric  valve 

] 

/ 


Round  ulcers 


\ 


"Etat  mamelonne ''''  ''  -y 
of  duodenum 


Papilla  of  Vater 


Small  ulcers 


-'..    First  portion  of 
'~^'.jJl  ''  duodenum  (consid- 
erably dilated) 


J'-^ 


""••SSffl^^^ 


'X'lcatricial  strand 
from  ulceration 


^■-Second  portion  of  duodenum 


Tig.  31. — Ulcer  of  the  Duodenum,  with  Secondary  Stenosis  of  the  Second  Portion 
AND  Dilatation  of  the  First  Portion.     (Personal  observation.) 

dilated  and  showed  several  ragged,  eroded  ulcers.  The  descend- 
ing portion  also  contained  sev^eral  similar  small  ulcerations,  some- 
what larger  than  lentils,  with  numerous  cicatricial  strands.  The 
latter  had  considerably  narrowed  the  lumen  of  the  descending  por- 
tion. 

Where  tubercular  symptoms  are  present  we  must  consider  the 
possibility  of  tubercular  ulcerations,  though,  as  shown  by  a  case  of 
Herz,^*^  under  these  circumstances  other  factors  may  produce  the 
stenosis  (e.  g.,  in  the  case  just  mentioned,  a  peritoneal  strand). 

In  advanced  age  we  must  first  think  of  cancer  of  the  duodenum 


352  DISEASES   OF   THE   INTESTINES 

and  its  surrounding  parts  as  the  cause  of  the  stenosis.  This  ques- 
tion is  discussed  in  the  chapter  on  Intestinal  ISTeoplasms,  to  wliich^ 
in  order  to  avoid  repetition,  we  refer. 

The  above  list  bj  no  means  includes  all  the  engendering  causes 
of  duodenal  stenosis.  To  desci'ibe  them  all  would  be  of  no  value, 
because  the  diagnosis  is  scarcely  ever  possible  during  life.  It  is 
safficient  to  simply  mention  the  other  possibilities,  so  that  they  may 
be  taken  into  account  in  appropriate  cases.  These  are  lymphomata, 
sarcomata,  kinking,  compression  by  metastatic  tumours,  pancreatic 
cysts,  fat  necrosis  of  the  pancreas,  cancer  of  the  pancreas,  retroperi- 
toneal tumours,  etc. 

Stenosis  of  the  Jejunum  and   Ileum 

Isolated  stenoses  of  the  jejunum  and  ileum  are  rare.  The  ma- 
jority owe  their  origin  to  the  adhesions  and  kinking  produced  by 
inflammatory  adhesions  with  the  (female)  genitals,  the  appendix, 
inflamed  and  reduced  hernia,  etc. 

In  rare  instances  healed  or  partially  healed  tubercular  ulcera- 
tions are  the  cause  of  the  stenosis.  Fibrous  stenosis,  analogous, 
to  hypertrophic  pylorus  stenosis,  is  of  anatomical  interest  only. 
It  has  been  studied  j)articularly  by  French  and  English  writers 
("  enterite  sclereuse,^^  "  plastic  linitis,"  "  cirrhosis  intestinalis "), 
and  affects  partly  the  stomach  and  partly  the  liver,  peritoneum, 
and  isolated  portions  of  the  intestine.  Cases  of  stricture  of  the 
small  intestine  from  unknown  cause  (syphilis  enteritis)  have  been 
reported ;  only  a  very  few  are  of  carcinomatous  nature  (Petrina,, 
Chouquet,  Letulbe,  Broscn,  E.  Hahn,  Keinke,  Wernich,  Kütt- 
ner^^).  Tubercular  stenoses  may  occur  isolated,  but  (more  fre- 
quently) are  multiple.  In  a  case  described  by  E.  FränkeP''',  and 
another  by  Hofmeister  ^^,  12  strictures  were  found.  The  strictures 
are  usually  situated  in  the  ileum,  occasionally  in  the  caecum,  and 
but  rarely  above  or  below  these  parts. 

On  the  whole,  the  clinical  picture  of  jejunal  and  ileal  stenosis 
is  but  Httle  characteristic.  The  higher  the  stricture  in  the  jejunum 
the  more  will  the  symptoms  of  disturbed  gastric  digestion  (par- 
ticularly vomiting)  preponderate ;  and  the  greater  the  degree  of 
the  stenosis  the  more  apt  is  the  vomiting  to  be  fascal  or  fecu- 
lent in  character.  The  nearer  the  stricture  is  to  the  caecum  the 
more  marked  are  the  actual  intestinal  symptoms — constipation, 
or  alternating  constipation  and  diarrhoea,  meteorism,  severe  colic, 
visible    and   palpable    intestinal    contraction,    particularly    in    the 


INTESTINAL  STENOSIS  353 

middle  of  the  abdomen — symptoms  which  differ  little  from  those 
of  stenosis  of  the  large  intestine. 

As  shown  by  the  observations  of  Litten  ^^  and  E.  Fränkel", 
marked  tubercular  stenoses  of  the  ileum  may  run  their  course  en- 
tirely, or  almost  entirely,  without  symptoms.  If  increasing  debility 
does  not  cause  death,  the  condition  becomes  recognisable  by  the 
development  either  of  intestinal  obstruction  or  of  an  acute  perfora- 
tive peritonitis. 

In  a  case  of  multiple  strictures  of  the  small  intestine,  of  unknown  character, 
reported  by  Faber '"',  besides  uncharacteristic  intestinal  disturbances,  there 
were  marked  symptoms  of  a  severe  pernicious  anaemia  from  which  the  patient 
died.  Faber  explained  the  pernicious  anaemia  by  absorption  of  certain  toxic 
products  which  developed  above  the  stenosis.  The  correctness  of  the  ex- 
planation may  be  questioned.  At  all  events,  the  occurrence  of  progressive 
anaemia  in  connection  with  stricture  of  the  small  intestine  is  interesting. 
According  to  Faber  the  same  observation  had  already  been  made  by  John- 
son and  Wallis  ^^. 

Since  stenosis  of  the  lower  small  intestine  produces  symptoms 
only  when  very  far  advanced,  the  diagnosis  is  very  difficult.  If  the 
diagnosis  of  a  jejuno-ileal  stenosis  has  already  been  established  by  a 
careful  analysis  of  the  history  and  of  other  data,  it  will  not  be  dif- 
ficult to  determine  its  character.  Moreover,  as  above  seen,  we  must 
always  think  of  the  possibility  of  multiple  intestinal  stenoses,  the 
clinical  diagnosis  of  which,  as  far  as  I  know,  has  never  been  made. 

Differential   Diagnosis 

The  differential  diagnosis  must  first  establish  the  fact  of  a  steno- 
sis of  the  upper  part  of  the  intestines,  and  then  more  exactly  define 
the  situation  as  well  as  the  cause  of  the  same. 

The  clinical  picture  of  high  duodenal  stenosis  is  so  similar  to 
that  of  pyloric  stenosis,  that,  as  previously  mentioned  (page  346), 
only  especially  favourable  circumstances  can  make  differentiation 
possible.  On  the  other  hand,  so  far  as  known,  the  permanent 
presence  of  bile  in  the  stomach  always  points  to  the  existence  of 
infrapapillary  duodenal  stenosis.  It  is  questionable  whether  the 
absence  of  bile  from  the  stomach  excludes  the  latter  disease.  In 
his  oft-quoted  work  Herz  concludes  that  in  dilatation  of  the  stom- 
ach the  presence  of  bile  may  not  be  recognised,  so  that  the  symp- 
toms of  pyloric  stenosis  predominate  in  the  clinical  picture.  But 
it  requires  further  confirmatory  evidence  to  determine  whether  this 
difficulty  can  be  overcome  by  washing  out  the  stomach  in  the  even- 


354  DISEASES  OF   THE   INTESTINES 

ings  and  examining  the  contents  of  the  fasting  stomach,  a  pro- 
cedure which  I  always  recommend. 

The  above  data  apply  to  the  differentiation  between  stenoses 
of  the  upper  segments  of  the  small  intestine  and  those  of  the 
lower.  There  is  generally  great  diificulty  in  distinguishing  be- 
tween a  deep  strictui'e  of  the  small  intestine  and  stricture  of 
the  large  intestine.  Subjectively  the  occurrence  of  frequent  diar- 
rhoea and  the  gastric  disturbances  (nausea,  vomiting,  anorexia,  etc.) 
may  be  of  diagnostic  value,  but  constipation,  and  alternate  con- 
stipation and  diarrhoea,  may  also  occur  in  stenosis  of  the  large 
intestine.  Objectively^  marked,  visible  peristalsis  may  lead  to  a 
probable  diagnosis  of  the  obstruction.  We  vdll  discuss  this  more 
fully  in  the  section  on  stenosis  of  the  large  intestine.  The  lower 
the  stenosis  the  more  feculent  will  be  the  masses  which  are 
regurgitated  into  the  stomach.  Finally,  in  deep  stenosis  of  the 
small  intestine,  particularly  when  far  advanced,  more  or  less  me- 
teorism  develops. 

In  the  determination  of  the  cause  of  the  stenosis  we  must  first 
decide  whether  the  process  is  malignant  or  benign.  If  malignancy 
can  be  excluded,  we  should  look  for  an  etiological  connection  be- 
tween some  previous  disease  and  the  benign  stricture.  In  stenosis 
of  the  upper  j^ortion  of  the  duodenum  we  ought  examine  for  dis- 
ease of  the  neighbouring  organs — of  the  liver,  gall  bladder,  pan- 
creas, and  right  kidney.  Lower  dovra  we  must  think  of  adhesions, 
of  kinking,  of  compression — conditions  produced  by  disease  of  the 
female  pelvic  organs,  the  appendix,  and  by  other  local  peritonitic 
processes.  The  other  varieties  of  stenosis  mentioned  above  are  of 
secondary  importance  ;  although  the  clinical  symptoms  be  very  com- 
plete their  diagnosis  is  sometimes  impossible. 

(J)  Stenosis  of  the  Large  Intestine 

The  subjective  symptoms  are  constipation  and  colic  associated 
with  nausea  and  vomiting.  The  constipation  has  significance  only 
in  connection  with  other  symptoms;  it  may  deserve  consideration 
because  of  the  manner  of  its  occurrence.  If  a  patient,  particularly 
one  in  advanced  life,  in  whom  the  intestinal  functions  have  always 
been  normal  and  who  has  not  changed  his  diet  or  way  of  living, 
suddenly  develop  constipation,  it  is  always  a  significant  symptom,  for 
habitual  constipation  is  not  a  disease  of  advanced  age,  but  of  youth 
and  middle  age.  Furthermore,  its  course  is  to  be  observed.  In 
contrast  to  simple  intestinal  atony,  this  constipation  does  not  develop- 


INTESTINAL  STENOSIS  355 

gradually,  but  very  rapidly,  and  it  reaches  its  highest  point  very 
quickly.  Laxatives  become  useless  in  a  few  weeks  or  months,  and 
the  patient  is  soon  forced  to  use  drastic  cathartics.  I  have  already 
called  attention  to  the  great  practical  importance  of  circumspection 
in  the  use  of  laxatives  in  consti23ation.  A  one-sided  view  of  this 
subject  should  not,  however,  be  taken,  for  exceptions  are  some- 
times met  with. 

In  other  cases  the  constipation  exists  for  years  as  a  harmless 
complaint,  before  it  becomes  more  severe.  The  patient  who  for- 
merly got  along  with  rhubarb  must  now  use  aloes,  bitter  waters,  or 
colocynth,  and  these  always  in  large  doses. 

In  addition,  spasmodic,  paroxysmal  intestinal  pains  call  atten- 
tion to  the  presence  of  an  intestinal  obstruction.  In  conjunction 
with  spasmodic  intestinal  rigidity  (soon  to  be  more  minutely  de- 
scribed), these  pains  assume  a  significant  character. 

Yomiting  is  an  important  and,  to  my  mind,  not  sufficiently 
valued  symptom  in  stenosis.  It  recurs  with  the  intestinal  colic,  and 
in  itself  presents  nothing  characteristic.  It  derives  its  importance, 
however,  from  the  fact  that  it  is  extremely  rare  in  stercoraceous 
flatulency.  If  the  vomiting  recurs  with  each  severe  attack  of 
colic,  it  ought  to  warn  the  practitioner  and  cause  him  to  suspect 
intestinal  stenosis. 

Objective  Synipto'ms. — The  most  important  objective  symptoms 
are  meteorism,  palpable  and  visible  intestinal  contractions  occur- 
ring at  intervals,  and  changes  in  the  character  of  the  stools. 

The  meteorism  varies  according  to  the  degree  and  seat  of  the 
intestinal  stricture.  It  is  scarcely  appreciable  in  strictures  of  the 
rectum  (to  be  described  later),  considerable  in  stricture  of  the 
descending  colon,  and  most  extensive  when  the  stricture  is  in 
the  upper  segments  of  the  large  intestine.  It  also  varies  with 
the  amount  of  fulness  of  the  suprastenotic  intestinal  segments. 
It  may  be  very  moderate  after  abundant  evacuation,  and  in- 
crease considerably  after  a  few  days  of  obstinate  constipation. 
It  depends  upon  the  sufficiency  of  the  hypertrophic  intestinal 
muscle  above  the  stricture — so  much  so  that  we  should  always 
regard  increasing  meteorism  as  a  precursor  of  approaching  intes- 
tinal paralysis  (eventually  in  connection  with  peritonitis).  As  long 
as  the  lumen  is  to  some  extent  permeable,  the  tympanites  will 
be  inconsiderable,  and  limited  to  one  or  both  iliac  regions  ("  flank 
meteorism,"  l^othnagel  *),  the  mesogastrium,  the  umbilical  region, 

*  Loc.  cit.,  p.  375. 


356  DISEASES   OF   THE   INTESTINES 

or  the  hypogastriura.  Therefore,  with  certain  reservations  we  can 
draw  important  conclusions  regarding  the  site  of  the  obstruction 
from  careful  observation  of  the  tympanites. 

We  can  sometimes  define  the  extent  of  the  tympanitic  area  by 
percussion,  or  better,  by  auscultatory  percussion.  IS'othnagel  has 
pointed  out  that  in  stenosis  of  the  large  intestine,  instead  of  the 
normal  more  or  less  marked  dulness  and  low  resonance  in  the 
upper  lumbar  region  posteriorly,  there  is  often  a  loud  and  deep 
percussion  note ;  this  is  present  on  both  sides  in  stenosis  of  the 
sigmoid  flexure  or  of  the  descending  colon,  and  only  on  the 
right  side  in  stenosis  of  the  splenic  flexure  or  of  the  transverse 
colon. 

Visible  peristalsis  associated  with  intestinal  rigidity  is  much 
more  significant  than  tympanites.  As  has  been  already  mentioned 
(page  68),  visible  peristalsis  as  such  not  infrequently  occurs  nor- 
mally in  emaciated  individuals,  particularly  in  women  with  dias- 
tasis of  the  recti  muscles  or  ptosis  of  the  abdominal  viscera. 
It  has  also  been  observed  as  a  motor  neurosis,  which  was  first 
described  by  Kussmaul  under  the  name  of  "  tormina  ventriculi." 
Both  forms,  however,  are  entirely  distinct  from  visible  intes- 
tinal peristalsis,  for  in  the  latter  the  intestinal  spasm  and  the 
circular  palpable  and  visible  intestinal  contraction  and  rigidity 
are  absent. 

In  every  spasmodic  peristaltic  action  several  phases  may  be 
distinguished :  a  gradual  onset,  which  is  accompanied  by  mo.d- 
erate  pain ;  steady  increase  of  the  pain  up  to  its  point  of  greatest 
severity  while  the  bowel  is  contracted  and  rigid ;  finally,  rapid 
abatement  of  the  attack,  with  the  occurrence  of  palpable  and 
audible  intestinal  sounds  — i.  e.,  sounds  of  gas  forced  through  the 
stricture. 

The  intestinal  contraction  may  be  limited  to  a  small  portion  of 
the  gut,  or  whole  coils  may  contract,  become  snakelike  and  swol- 
len, and  again  relax.  The  former  variety  (limited  contraction)  is 
observed  principally  in  stenosis  of  the  colon  below  the  csecum,  the 
latter  in  stenosis  of  the  csecum  and  small  intestine.  The  degree  of 
the  stenosis  will  naturally  greatly  influence  the  extent  of  the  tetan- 
ically  contracting  intestines  involved,  and  the  frequency  of  the 
attacks. 

Can  any  conclusions  as  to  the  seat  of  the  obstruction  be  drawn 
from  the  configuration  of  the  intestinal  rigidity  ? 

Based  upon  the  experience  of  others  and  myself  in  this  relation, 


INTESTINAL  STENOSIS  357 

this  question  must  be  answered  in  the  affirmative.  Thus  it  is 
easy  to  recognise  a  caecal  stenosis  from  the  active  peristalsis  of  the 
small  intestine.  Stenoses  lower  down  are  also  easily  recognised  if 
rigidity  of  the  large  intestine  is  well  defined.  Nothnagel  *  cor- 
rectly states  that  errors  can  only  arise  when  the  intestine  adjoining 
the  stricture  has  lost  its  power  of  contraction,  and  the  segment 
immediately  above  acts  vicariously  for  the  latter. 

The  important  facts  regarding  the  character  of  the  stools  in 
stenosis  of  the  large  intestine  have  already  been  described  in  the 
chapter  on  Neoplasms  (pages  310  and  311),  as  well  as  under  the  gen- 
eral symptomatology  of  the  present  chapter  (page  345).  In  both 
places  we  have  mentioned  the  slight  significance  of  this  symptom, 
and  we  wish  to  repeat  here  that  the  absence  of  stenotic  stools  does 
not  exclude  the  diagnosis  of  stenosis  of  the  large  intestine.  The  ad- 
mixture of  pus  and  blood  in  the  stools  is  not  chamcteristic  of  intes- 
tinal stenosis,  but  only  indicates  the  presence  of  complications — 
neoplasms,  hemorrhoids,  partial  or  chronic  intussusception,  ster- 
coraceous  ulcers,  etc. 

Very  rarely  all  these  symptoms  are  combined.  In  such  instances 
we  must  be  content  with  a  probable  diagnosis.  At  all  events,  when 
"well-defined  symptoms  of  stenosis  of  the  large  intestine  are  present 
the  diagnosis  will  not  long  remain  in  doubt. 

The  question  of  the  cause  of  the  stenosis  is  a  much  more  difficult 
one.  The  history  gives  us  considerable  assistance.  It  may  inform 
us  respecting  previous  dysentery,  tubercular  disease  of  the  intes- 
tine, or  of  other  organs,  occasionally  of  syphilis,  appendicitis,  peri- 
tonitis, in  women,  puerperal  fever  and  other  diseases  of  the  geni- 
tal tract,  incarcerated  hernia,  intestinal  obstruction,  abdominal 
operations.  In  this  manner  we  may  gain  valuable  hints  for  the 
diagnosis. 

The  examination  per  rectum,  and  in  women  per  vaginam,  is  of 
importance  and  should  never  be  neglected.  Thus  in  an  otherwise 
well-defined  case  of  stricture  of  the  large  bowel,  I  was  recently 
able  to  distinctly  palpate  a  contracting  coil  of  small  intestine  in 
the  small  pelvis.  In  some  cases  vaginal  examination,  or  com- 
bined rectal  and  vaginal  examination,  may  give  important  informa- 
tion regarding  the  situation  and  character  of  a  suspected  stenosis 
of  the  large  intestine. 

The   external   examination  of  the  abdomen  is,  however,  most 

*  Loc.  cit..  p.  376. 
24 


358  DISEASES  OP   THE  INTESTINES 

instructive.  If  a  tumour  can  be  felt,  and  its  precise  nature  is  in 
donbt,  a  careful  examination  is  necessary,  with  especial  considera- 
tion of  the  age  of  the  patient  and  the  comparative  frequency  of 
the  various  tumours  (the  rarity  of  benign,  the  much  greater  fre- 
quency of  malignant  neoplasms). 

Differential  Diagnosis 

A  description  of  the  etiology  has  already  been  given.  When 
spasmodic  intestinal  contractions  are  absent  it  will  be  difficult  to 
avoid  diagnostic  errors.  This  will  be  the  case,  for  instance,  in 
intestinal  stenosis  when  the  obstruction  is  not  as  yet  marked  or 
can  be  easily  overcome  by  contraction  of  the  intestine  above  the 
stricture.  If  there  is  no  marked  disturbance  of  nutrition,  as 
in  intestinal  cancer,  the  patients  do  not  as  a  rule  present  them- 
selves for  medical  examination  at  this  early  stage  of  the  disease.  As 
already  mentioned,  the  presence  of  the  initial  symptoms  of  stricture, 
be  they  ever  so  slight,  should  make  us  suspect  a  mechanical  obstruc- 
tion in  the  bowel.  If,  in  addition,  the  history  confirms  our  suspi- 
cion and  other  objective  signs  of  disturbed  intestinal  functions  are 
present  (diarrhoeas,  blood,  pus,  and  loss  of  weight),  it  may  be 
possible  to  make  an  early  diagnosis.  It  need  hardly  be  men- 
tioned that  if  tumours,  adhesions,  and  infiltrations  about  the  large 
intestine  are  found,  they  offer  important  data  for  clearing  up 
the  diagnosis.  Despite  these  favourable  conditions  and  because  of 
the  many  other  etiological  possibilities  there  will  always  be  doubtful 
cases.  It  is  impossible  to  consider  all  the  differential  diagnostic  data, 
for  we  should  become  lost  in  the  immense  literature  of  the  subject.. 

B.     INTESTINAL    OBSTRUCTION    (Ileus) 

Intestinal  obstruction  is  a  condition  in  which  the  lumen  of  one 
or  more  portions  of  the  intestines  is  occluded,  and  the  normal 
forward  movement  of  the  contents  entirely  suspended.  Since  the 
earliest  days  of  medicine  the  resulting  clinical  picture  has  been 
called  ileus  (from  eiXeeco  =  misereor,  or  e/Aeco  ^  torqueo). 

In  his  book  on  intestinal  diseases,  Nothnagel  advocates  the  discontinu- 
ance of  the  term  ileus.  It  is  true  that  the  ileus  of  the  older  physicians,  with 
its  extremely  vague  meaning,  has  not  the  same  significance  as  the  ileus  of 
to-day.  The  word  as  used  at  j^resent  may  stand  as  a  short  and  forcible  desig- 
nation for  intestinal  obstruction.  For  purely  practical  reasons  we  shall  retain 
the  old  classification,  as  accepted  by  Leichtenstern,  of  mechanical,  dynamic,, 
and  mechanico-dynamic  ileus. 


INTESTINAL  OBSTRUCTION  359 

Through  interference  with  the  normal  course  of  the  faeces  at  any 
point,  a  number  of  severe  symptoms  soon  develops.  These  gen- 
erally begin  suddenly,  soon  become  very  severe,  and  either  cease 
spontaneously,  or,  if  not  cured  by  internal  or  surgical  means,  cause 
the  death  of  the  patient. 

We  shall  describe  those  varieties  of  intestinal  obstruction  which 
are  especially  important  to  internal  medicine.  The  obstructions 
produced  by  external  hernia  will  be  incidentally  touched  upon,  since 
they  are  treated  of  in  surgical  text-books. 

General  Symptomatology  and  Diagnosis  of  Intestinal 
Obstruction 

As  a  typical  example,  let  us  take  an  acute  obstruction  of  the  small 
intestines  due  to  strangulation :  An  individual,  previously  healthy, 
is  suddenly  seized  with  severe  colicky  pains  in  the  abdomen,  vomit- 
ing of  the  ingesta,  partially  or  not  at  all  digested.  There  is  abso- 
lute anorexia,  the  abdomen  rapidly  becomes  distended,  neither  fseces 
nor  flatus  are  passed.  Intense  nausea  is  present  even  when  the 
stomach  is  empty.  The  urine  is  diminished,  or  there  is  anuria. 
There  is  severe  thirst,  particularly  after  repeated  vomiting.  The 
patient  looks  very  ill  as  if  sufEering  from  a  severe  acute  disease. 

The  vomiting  consists  at  first  of  food  remnants,  and  when  the 
stomach  is  empty  is  bile-tinged  or  grayish-green ;  gradually  it 
becomes  feculent,  and  finally  fsecal. 

With  the  onset  of  the  vomiting  pain  and  meteorism  may  tem- 
porarily cease,  giving  new  hope  to  the  patient  and  relatives,  or 
to  the  physician.  The  sym]3tonis  very  soon  become  aggravated  ; 
the  pain  reappears,  the  abdomen  becomes  more  tympanitic,  and 
even  by  the  laity  the  repeated  severe  fsecal  vomiting  is  recognised 
as  a  sign  of  intestinal  obstruction. 

There  is  also  a  marked  change  in  the  patient's  general  condi- 
tion. The  lack  of  nourishment,  the  loss  of  sleep  produced  by  the 
pain  and  vomiting,  and,  above  all,  the  shock  caused  by  the  strangu- 
lation, produce  a  condition  of  deep  collapse.  In  sharp  contrast  to 
the  latter,  the  patient  retains  full  consciousness,  and  only  just  before 
death  may  delirium  appear.  This  condition  of  extreme  collapse, 
which  has  not  inaptly  been  compared  to  the  algid  stage  of  cholera, 
is  soon  followed  by  dissolution. 

This  is  a  short  description  of  a  typical  case  of  acute  obstruc- 
tion. The  several  symptoms,  and  particularly  the  objective  clinical 
picture,  require  a  closer  study.     To  avoid  repetition  it  is  best  to 


360  DISEASES  OF  THE  INTESTINES 

analyze  both  together  and  to  point  out  their  significance.  For 
this  purpose  the  general  symptoms  relating  to  intestinal  ob- 
struction will  first  be  considered,  and  the  special  diagnosis  of 
the  several  varieties  of  obstruction  will  be  reserved  for  later  dis- 
cussion. 

The  subjectwe  symptoms  are  pain,  nausea,  vomiting,  retention 
of  gas  and  faeces. 

1.  Pain. — This  constitutes  the  main  symptom  of  intestinal 
obstruction.  It  is  present  in  all  forms,  but  it  may  vary  in  inten- 
sity and  other  characteristics. 

The  pain  is  most  intense  and  continuous  in  obstruction  of  the 
small  intestine,  independent  of  its  anatomical  cause.  Its  severity 
is  such  that  even  strong  people  are  overcome.  The  pains  are 
more  continuous  in  character  than  in  stenosis.  As  I  have  already 
mentioned  in  the  general  division  (page  58),  Treves ^'^  gives  great 
diagnostic  importance  to  this  sign.  This  is  true,  however,  only 
with  certain  limitations.  The  seat  and  type  of  obstruction  are 
doubtlessly  prominent  factors.  In  the  first  place,  as  several  cases 
of  incomplete  intestinal  obstruction  reported  by  Treves  show, 
the  pain  may  be  intermittent  in  character,  and  this  may  be  the 
case  in  well-marked  obstruction  of  the  small  intestines  provided 
copious  vomiting  affords  temporary  relief  to  the  occluded  bowel 
segment.  The  continuance  or  discontinuance  of  the  pain  may  be 
obscured  by  the  use  of  narcotics  and  stomach  lavage,  but  we  must 
in  general  agree  with  the  conclusions  of  Treves  ^^.  It  is  important 
to  note  whether  the  pain,  which  was  continuous,  shows  marked 
remissions,  for  with  cautious  reservations  this  would  point  either 
to  a  favourable  termination  or  to  a  transition  from  a  complete  to 
an  incomplete  obstruction. 

The  localization  of  the  pain  possesses  on  the  whole  no  great 
significance.  In  the  majority  of  cases  the  pain  is  localized  in  the 
neighbourhood  of  the  umbilicus,  but,  as  Treves  has  demonstrated, 
this  by  no  means  signifies  that  the  site  of  the  obstruction  is  to  be 
sought  for  in  that  region. 

We  must  distinguish  between  abdominal  sensitiveness  to  jpi^essure 
and  subjective  pain.  The  former  is  generally  absent  in  the  begin- 
ning of  the  disease ;  in  the  later  stages  it  may  be  either  circum- 
scribed or  diffuse.  Circumscribed  pressure  sensitiveness  occasion- 
ally occurs  in  the  first  days  of  the  obstruction  ;  it  then  has  a  certain 
significance,  since  it  points  either  to  an  active  inflammation  of  the 
intestine  in  question  or  to  a  local  peritonitis.     Difl:use  sensitiveness. 


INTESTINAL   OBSTRUCTION  361 

in  connection  witli  other  symptoms  (fever,  etc.),  points  to  a 
general  peritonitis.  Treves  speaks  of  another  form  of  sensi- 
tiveness which  is  developed  late  in  the  disease,  and  which  is 
to  be  looked  upon  as  the  consequence  of  spasmodic  intestinal 
peristalsis.  In  contrast  to  diffuse  peritonitis,  this  sensitiveness  is 
only  moderate. 

In  all  varieties  of  obstruction  pain  may  cease  toward  the  end  of 
the  disease.  ISTothnagel  believes  this  is  due  to  intestinal  paralysis 
or  to  perforative  peritonitis,  but  it  is  probably  also  caused  by  the 
ensuing  collapse  and  lessened  vitality. 

2.  Vomiting. — This  is  one  of  the  most  regular  symptoms  of 
the  disease.  The  initial  vomiting  is  no  doubt  reflex  in  character, 
analogous  to  the  vomiting  of  acute  peritonitis,  of  gallstone  and 
kidney-stone  colic,  or  of  pregnancy.  In  the  beginning  the  vomited 
matter  almost  always  consists  of  the  stomach  contents  or  mucus, 
and,  if  severe,  contains  bile. 

The  transition  to  stercoraceous  vomiting  is  recognised  by  the 
bringing  up  of  brown,  slightly  fetid,  or  feculent  masses.  When  the 
obstruction  has  developed  very  acutely,  the  vomiting  may  be  fsecal 
from  the  very  beginning.  Fsecal  vomiting  consists  of  fluid,  or 
occasionally  of  fragmentary  brownish-yellow  or  brown-coloured 
masses.  Yomiting  of  formed  scybala,  which  is  reported  by  well- 
known  clinicians  (Rosenstein  ^,  Jaccoud^,  Briquet  ^^),  is  certainly 
extremely  rare. 

Ever  since  the  time  of  Galen  the  cause  of  stercoraceous  vomit- 
ing has  been  the  subject  of  lively  discussion.  We  shall  briefly  con- 
sider some  of  the  theories  which  have  been  offered. 

The  old  idea  that  fsecal  vomiting  depends  upon  perfect  or  imperfect  action 
of  the  ileo-csecal  valve  must  be  given  up,  in  view  of  the  fact  that  such  vomiting 
occurs  in  obstruction  of  the  small  as  well  as  of  the  large  intestine.  It  must 
be  admitted,  however,  that  in  the  latter  instance  there  is  an  insufficienc\'  of 
Bauhin's  valve,  the  valve  being  capable  of  offering  only  a  certain  relative  resist- 
ance to  the  pressure  of  the  stagnant  fsecal  mass.  For  a  long  time  the  exist- 
ence of  antiperistalsis  has  been  disputed.  That  antiperistalsis  vxay  occur, 
has  been  proved  by  Nothnagel's  experiments  on  rabbits  with  common  salt, 
but  Nothnagel  has  never  tested  his  theory  in  intestinal  stenosis.  The  ex- 
planation given  by  Haguenot  in  1813,  as  reported  by  Leichtenstern^^,  is  ample 
for  the  comprehension  of  faecal  vomiting.  It  is  briefly  as  follows  :  Strong  pres- 
sure is  brought  to  bear  upon  the  site  of  obstruction  by  the  accumulating  faeces 
and  gas,  and  this  pressure  is  increased  by  every  respiration,  by  every  act  of 
vomiting,  and  by  every  active  intestinal  contraction.  Since  the  stagnant  intes- 
tinal contents  have  no  other  avenue  o^  escape,  it  is  apparent  that  even  the  act 
of  vomiting,  accompanied  as  it  is  by  contraction  of  the  diaphragm  and  abdom- 


362  DISEASES   OP  THE  INTESTINES 

inal  muscles,  will  force  these  masses  toward  the  stomach.  In  like  manner, 
the  tympanitic  intestines  may  act  as  stimuli  in  forcing  the  stagnant  masses 
toward  the  stomach.  Henle  appropriately  called  this  an  "overflow  "  of  fluid 
into  the  stomach.  Haguenot's  theory  also  explains  why  faecal  vomiting  occurs 
much  easier  and  more  extensively  in  obstruction  of  the  small  than  of  the  large 
intestines. 

Because  it  is  easily  recognised,  fsecal  vomiting  is  one  of  the  most 
important  symptoms  of  organic  intestinal  obstruction.  We  shall 
see  later,  however,  that  it  may  also  be  present  in  simple  spastic  and 
paralytic  intestinal  obstruction  (compare  page  403). 

3.  Constipation. — In  complete  intestinal  obstruction  constipa- 
tion is  generally  absolute,  and  continues  as  long  as  the  disease. 
Neither  faeces  nor  gas  are  passed.  To  this  rule  there  are  a  very  few- 
noteworthy  exceptions.  Rectal  irrigations  may  wash  out  small  faecal 
particles  from  the  intestines  below  the  site  of  the  occlusion,  but 
these  are  small,  and  always  consist  of  faeces  that  were  adherent  to 
the  intestinal  walls  {Randkoth).  It  is  important  to  note  that,  in 
these  cases,  flatus  is  always  absent.  Besides  such  stools,  Treves  ^^ 
has  reported  several  cases  with  autopsies,  in  which  more  or  less 
abundant  evacuations  were  present  during  the  course  of  the  disease. 
Some  of  these  cases  he  explained  by  sudden  intestinal  peristalsis  from 
an  intercurrent  peritonitis  (?).  The  explanation  is  much  clearer  in 
two  of  the  cases.  In  the  one  instance  there  was  an  incarceration  of 
about  20  centimetres  of  the  ileum  produced  by  a  strand  running 
from  the  transverse  colon  to  the  caecum.  An  intestinal  ulcer  had 
perforated,  the  tension  of  the  distended  intestines  was  thus  lessened, 
and  the  incarcerated  coil  was  thereby  enabled  partly  to  escape  from 
the  constricting  bands. 

In  partial  volvulus  of  the  small  intestine  or  sigmoid  flexure 
some  faeces  may  be  passed.  Abundant  evacuations  are  by  no  means 
rare  in  acute  intestinal  invagination. 

In  the  article  already  cited.  Litten  ^^  describes  a  case  of  multiple 
tubercular  strictures  of  the  small  intestine,  in  which  both  profuse 
diarrhoea  and  faecal  vomiting  were  present.  He  correctly  concludes 
that  there  was  very  advanced  though  not  complete  obstruction  of 
the  bowel. 

Finally,  J^aunyn  has  pointed  out  the  paradoxical  occurrence  of 
evacuations  in  obstructions  by  gallstones.  When  we  come  to  de- 
scribe the  various  kinds  of  intestinal  obstruction  we  shall  more  fully 
analyze  these  difl^erent  features,  which  are  so  important  for  the  semei- 
ology  of  this  affection. 


INTESTINAL   OBSTRUCTION  363 

Objective  Signs. — These  are  tympanites,  visible  peristalsis,  intes- 
tinal liemorrhage,  changes  in  the  urine,  and  disturbances  of  general 
health. 

1.  Tympanites  is  always  present  in  intestinal  obstruction,  but  its 
amount  varies.  In  acute  obstruction  of  the  small  intestines,  with 
«udden  onset,  it  is  relatively  slight.  The  tympanites  is  extremely 
marked  in  obstruction  of  the  large  intestine,  particularly  in  its  most 
frequent  form — volvulus  of  the  sigmoid  flexure.  In  the  present 
state  of  our  knowledge  we  may  distinguish  two  forms  of  tympanites, 
tympanites  due  to  stagnation  of  contents  and  local  tympanites. 
The  former  develops  in  the  large  or  small  intestines  when  the 
lumen  is  obstructed  by  foreign  bodies,  invagination,  impacted  faeces, 
etc.  Fluids  and  gas  stagnate  above  the  stenosis  and  distend  the 
bowel,  and  the  less  the  amount  of  gas  absorbed  the  greater  the  dis- 
tention (Zuntz  and  Tacker). 

In  the  beginning  of  the  disease,  when  the  intestinal  wall  is  still 
fairly  intact,  meteorisra  will  be  only  moderate  ;  it  gradually  increases 
with  destruction  and  over-distention  of  the  intestinal  wall. 

Local  tympanites.,  already  reported  by  Kiittner^'^  and  Hilton 
Fagge^^,  is  very  much  more  important  than  the  above  form.  Its 
importance  as  a  diagnostic  factor,  however,  is  due  especially  to  von 
Wahl  and  his  pupils,  von  Zöge-Manteuifel  and  Kader,  as  well  as  to 
Obalinski  and  Schlange.  Yon  "Wahl  ^^  first  called  attention  to  the 
apparent  paradox,  that  in  intestinal  obstruction  where  the  tympa- 
nites is  most  marked  (volvulus,  invagination,  kinking)  the  coil  in 
which  the  obstruction  exists  is  the  most  tympanitic,  for  it  is  this 
very  coil  which,  through  disturbance  of  its  circulation  and  putre- 
faction of  its  contents,  is  the  first  to  be  distended  by  gas.  The 
formation  of  gas  is  accompanied  by  considerable  distention  of  the 
bowel  wall,  and  very  rapid  complete  paralysis. 

This  distended,  resistant,  and  immovable  por- 
tion of  the  intestine  is  recognised  by  inspection 
from  the  shape  of  the  abdomen,  and  by  palpation, 
from  its  clearly  increased  resistance  (von  Wahl). 

From  extensive  experiments  on  animals,  Kader  ^'^  has  given  us 
conclusive  proof  of  von  Wahl's  theories,  and  has  explained  satis- 
factorily the  occurrence  of  local  meteorism.  This  experimenter 
showed  that  the  chief  cause  of  the  meteorism  lies  in  the  disturb- 
ance of  the  circulation  of  the  intestinal  wall ;  the  tympanites  is 
explained  by  the  increase  in  the  size  of  the  bowel,  which  is  pro- 
duced by  the  following  three  factors  :    infiltration  of  the  intestinal 


364  DISBASES  OF  THE  INTESTINES 

wall,  accumulation  of  fluids  in  the  canal,  and  the  development  of 
gases  in  the  interior  of  the  intestine.  The  bowel  segment  in  ques- 
tion soon  becomes  distended  and  tense,  often  within  a  few  hours. 
Changes  in  the  intestinal  wall  (oedema,  hemorrhagic  infiltration^ 
thickening  of  the  intestinal  wall  and  its  mesentery)  occur  through- 
out the  obstructed  segment  and  are  limited  to  this  part.  Finally, 
there  is  gangrene  of  the  intestine,  frequently  with  perforation  into 
the  abdominal  cavity.  These  perforations  are  often  so  minute  that 
they  are  only  demonstrable  by  distending  the  bowel  under  water. 
As  to  the  diagnostic  value  of  this  fixed,  distended  coil  of  intestine, 
when  the  clinical  symptoms  are  well  marked,  its  presence  is  doubt- 
less sufficient,  and  occasionally  even  conclusive.  Its  recognition 
necessitates  a  series  of  careful  examinations.  According  to  the 
description  of  von  Zöge-ManteuffeP^,  the  method  of  the  examina- 
tion of  this  tympanitic  coil  is  as  follows :  "  After  the  history  has 
been  taken  and  the  general  condition  of  the  patient  noted,  the 
abdomen  should  be  carefully  inspected.  The  smallest  asymmetry 
must  be  taken  into  account.  We  should  observe  whether  the  asym- 
metry remains  constant,  whether  it  changes  with  active  peristalsis, 
whether  intestinal  movements  become  apparent,  or  whether — and 
this  is  very  important — there  be  not  abnormal  quiet  beneath  the 
tense,  distended  abdominal  walls.  Palpation,  which  follows  inspec- 
tion, must  attempt  to  establish  differences  of  resistance.  On  pal- 
pation, a  strangulated,  tympanitic  coil  of  intestine  feels  quite  differ- 
ent from  the  normal  intestine  containing  fluid  faeces.  Requiring 
more  space,  it  forces  itself  against  the  yielding  abdominal  wall,  and 
is  thus  directly  accessible  to  examination.  If  vomiting  occurs,  the 
resulting  relief  of  tension  may  enable  one  to  grasp  this  resistant 
segment.  This  is  especially  easily  accomplished  during  chloroform 
narcosis." 

The  diagnosis  of  internal  incarceration,  strangulation,  or  volvulus 
is  facilitated  if  such  a  distended  immovable  coil  of  intestine  is  pres- 
ent. Based  upon  von  Wahl's  symptom,  the  diagnosis  of  these  forms 
of  intestinal  obstruction  has  repeatedly  been  correctly  made,  and  the 
cases  thereupon  successfully  operated.  But  von  Wahl's  sign  is 
not  absolutely  trustworthy,  when,  for  instance,  as  he  himself 
states,  a  larger  intestinal  mass  is  strangulated.  Schede  ^^  points  out 
that  the  fixed  intestinal  coil  may  be  covered  by  distended  intes- 
tines lying  above  the  obstruction.  Despite  all  this,  however,  we 
shall  have  to  look  for  von  Wahl's  sign  in  every  case  of  intestinal 
obstruction. 


INTESTINAL   OBSTRUCTION  365 

2.  Spasmodic  Intestinal  Peristalsis. — Though  a  classic  symptom 
of  chronic  intestinal  obstruction,  spasmodic  intestinal  peristalsis, 
according  to  the  opinion  of  all  careful  observers,  is  one  of  the  rarer 
symptoms  of  aciite  intestinal  obstruction.  Fenwick^  denies  its 
occurrence;  Nothnagel*  mentions  it,  but  directs  attention  to  the 
great  contrast  between  the  marked  intestinal  rigidity  in  stenosis  and 
its  weak  contraction  in  complete  occlusion.  Schlange  ^,  Obalinski  ^^, 
and  ISTaunyn^''^  consider  the  slight  peristalsis  of  the  "fixed  coil  "a 
very  important  symptom  of  acute  intestinal  obstruction.  The 
first  two  authors  also  consider  it  of  practical  significance  for  it 
indicates  vital  irritability  of  the  bowel ;  but  this  statement  is  dis- 
puted by  von  Zöge-Manteuffel.  According  to  Schlange,  peri- 
stalsis of  the  intestine  proximate  to  the  obstruction  is  best  ob- 
served in  strangulation  of  smaller  coils  and  in  obstruction  by 
obturation.  Naunyn,  who  has  described  a  case  in  point,  states 
that  this  phenomenon  may  also  occur  in  volvulus  without  strangu- 
lation. I  myself  have  never  observed  intestinal  peristalsis  in  acute 
obstruction  in  the  course  of  a  chronic  stenosis,  and  I  consider  the 
absence  of  such  peristalsis  as  an  evidence  of  a  coinplete  intestinal 
obstruction. 

3.  Intestinal  hemorrhages  may  occur  under  several  conditions. 
They  are  most  frequent  in  intussusception,  but,  as  Henoch  and 
Wilms  have  shown,  are  occasionally  found  after  herniotomy,  after 
reduction  of  the  hernia  (Schnitzler),  in  strangulation,  gallstone 
obstruction,  and  more  frequently  in  vohoilus  of  the  sigmoid  flex- 
ure and  other  portions  of  the  intestines.  As  Tietze  ^  has  recently 
demonstrated,  hematemesis  may  occur  in  intestinal  obstruction 
as  a  result  of  severe  destructive  tissue  changes  in  the  proximal 
segment.  Intestinal  hemorrhage  is  only  of  significance  in  con- 
nection with  the  symptoms.  "When  present,  it  speaks  rather  for 
strangulation  of  the  small  intestine  than  for  obturation.  We  have 
already  mentioned,  in  the  chapter  on  Intestinal  Carcinoma  (page  308), 
that  hematemesis  may  also  occur  in  stenosis  of  the  large  intestine. 

4.  Changes  in  the  Urine. — The  excretion  of  urine  is  dimin- 
ished on  account  of  the  very  rapid  collapse,  the  vomiting  and  the 
little  nourishment  taken.  This  oliguria  is  not  especially  charac- 
teristic, but  the  indicanuria  which  is  frequently  present  may, 
according  to  JafEe,  have  a  certain  diagnostic  significance  in  re- 
lation to  the  site  of   obstruction,      Numerous  examinations  have 

*  Log.  cit.,  p.  211. 


366  DISEASES  OF   THE   INTESTINES 

confirmed  Jaffe's  claims  that  marked  indicanuria  is  present  in 
the  first  days  of  obstruction  of  the  small  intestine,  and  may  be 
of  diagnostic  value.  If  at  such  time  marked  indicanuria  is  ab- 
sent,  it  would  speak  rather  for  occlusion  of  the  large  intestine. 
Later  in  the  disease  pronounced  indicanuria  may  also  occur  in 
obstruction  of  the  large  intestine,  and  hence  loses  all  significance. 
If  even  then  no  indican  is  present  it  would  point  still  more  to  an 
obstruction  of  the  large  intestine.  Indican  may  be  increased  in 
other  affections  than  intestinal  obstruction,  and  its  value  must 
always  be  cautiously  accepted. 

What  is  true  of  indicanuria  is  also  true  of  Rosenbach's  reaction. 
I  have  never  heard  of  a  marked  Eosenbach  reaction  that  was  not 
accompanied  by  an  increase  of  indican  in  the  urine. 

Besides  indicanuria  we  may  find  albumin  and  casts,  particularly  in  incar- 
cerated hernise  (Englisch^',  Frank*"),  and  in  severe  intestinal  stenoses  (von 
Engel*');  hemorrhagic  nephritis  vpas  observed  by  Israel  in  a  case  of  volvulus 
of  the  sigmoid  flexure  *^. 

5.  General  Condition. — In  all  varieties  of  intestinal  obstruc- 
tion the  general  condition  of  the  patient  suffers  greatly.  ITaturally 
there  are  differences  in  the  several  forms  of  obstruction.  Age,  con- 
stitution, and  other  factors  have  their  infiuence  here  as  they  do  in 
other  pathological  conditions,  all,  however,  being  of  secondary 
importance  to  the  shock.  To  a  certain  extent  the  degree  of  the 
shock  indicates  the  site  and  perhaps  the  nature  of  the  obstruction. 
Thus  it  is  a  well-known  fact  that  in  occlusion  of  the  small  intes- 
tine, particularly  its  most  frequent  pernicious  variety — strangula- 
tions and  incarcerated  hernise — the  clinical  symptoms  very  rapidly 
reach  their  greatest  severity.  Obstruction  of  the  large  intestine, 
on  the  other  hand,  is  more  gradual  in  its  development,  and  hence 
the  collapse  is  less  severe  and  is  more  slowly  developed.  We  can- 
not here  go  into  the  details  of  the  theory  of  collapse,  in  which 
different  factors  require  consideration  (reflex  action,  loss  of  water, 
intoxication,  peritonitis,  cardiac  insufficiency,  etc.). 

6.  Clinical  Examination. — Clinical  examination  may  give  us 
valuable  aid.  The  well-known  rule — very  careful  examination  of 
the  external  hernial  orifices  in  cases  of  intestinal  obstruction — should 
never  be  forgotten.  We  must  first  of  all  determine  whether  an 
incarcerated  hernia  has  been  actually  or  partially  i-educed  en  masse. 
Medical  literature  abounds  with  cases  of  obstruction  due  to  incom- 
plete or  apparent  reduction.      Digital  examination  of  the  vagina 


INTESTINAL   OBSTRUCTION  36Y 

and  rectum  is  quite  important,  and  sometimes  gives  useful  in- 
formation. 

In  the  general  division  we  have  mentioned  the  most  important 
considerations  regarding  inspection,  percussion,  auscultation,  and 
palpation.  I  would  again  mention  the  diagnostic  value  of  auscul- 
tatory percussion^  first  described  by  Leichtenstern  *  and  later  by 
Curschmann  ^^,  by  means  of  which  it  is  often  possible  to  localize  dif- 
ferent portions  of  the  intestines. 

The  significance  of  distention  of  the  rectum  with  air  and  liquids 
has  already  been  treated  of  at  length  in  the  general  division.  We 
again  repeat  that  these  methods  may  serve  to  confirm  a  diagnosis  of 
obstruction  in  the  lower  portions  of  the  intestine,  though  they  are 
useless  in  obstructions  higher  up. 

Differential  Diagnosis  of  Intestinal  Obsteuction 

If  the  clinical  picture  of  obstruction  is  well  developed,  and  its 
course  can  be  followed  from  the  onset,  the  diiferential  diagnosis 
between  ileus  and  its  related  conditions  is  rarely  diflicult.  If, 
however,  the  beginning  be  obscure,  the  symptoms  not  well  marked, 
or  complications  present,  the  diagnosis  becomes  very  difficult. 
Among  the  conditions  which  are  generally  easily  differentiated 
from  intestinal  obstruction  are  flatulent  colic,  cholelithiasis  and 
nephrolithiasis,  poisoning,  and  cholera. 

1.  Flatulent  Colic. — If  observed  in  the  earliest  stages,  differen- 
tiation between  intestinal  obstruction  and  flatulent  colic  may  be 
difficult,  particularly  if  the  severe  symptoms  of  obstruction  have 
gradually  developed.  The  history,  clinical  examination,  and  the 
further  course  of  the  disease  are  important  in  this  connection. 
The  history  shows  that  the  patient  has  often  suffered  from  similar 
attacks  as  well  as  from  irregular  bowels.  Symptoms  of  severe 
shock  are  absent  in  intestinal  colic.  Though  flatus  is  generally 
not  passed  in  such  cases,  some  gas  may  be  passed  and  thereby  relief 
obtained.  Yomiting,  one  of  the  early  symptoms  of  intestinal  ob- 
struction, is  very  rarely  present  in  simple  flatulent  colic.  Further 
observation  will  scarcely  ever  leave  any  doubt  as  to  the  nature  of 
the  disease. 

2.  Gallstone  and  Renal  Colic. — In  the  beginning  of  the  attack 
biliary  and  renal  colic  may  very  much  resemble  intestinal  obstruc- 
tion, especially  an  obstruction  situated  high  up.     Here,  again,  the  his- 

*  Loc.  eit.,  p.  407. 


368  DISEASES   OP   THE   INTESTINES 

torj  is  important.  Biliary  and  renal  colics  usually  occur  late  in  life, 
intestinal  obstruction  is  found  at  all  ages.  It  may  be  possible  to  pal- 
pate the  gall  bladder  or  an  enlarged  painful  liver  or  painful  kidney. 
The  presence  of  slight  icterus  or  of  urine  containing  a  small  amount 
of  bilirubin,  or  of  cloudy  urine  containing  a  marked  sediment,  may 
point  to  the  correct  diagnosis.  Finally,  the  presence  of  very  marked 
indicanuria  in  the  beginning  of  the  disease  may  aid  in  the  differen- 
tiation.   "With  careful  observation  the  diagnosis  should  soon  be  made. 

3.  Poisoning  has  several  times  been  mistaken  for  obstruction. 
On  the  whole,  however,  error  can  only  occur  when  no  history  can 
be  obtained  or  when  the  disease  runs  a  very  atypical  course. 

4.  As  recent  reports  have  shown,  cholera  nostras  or  Asiatica 
may  cause  dangerous  mistakes,  especially  during  a  cholera  epi- 
demic, and  particularly  when  that  rare  complication  of  obstruction 
first  described  by  Malgaigne — obstruction  with  profuse  diarrhoeas 
(cholera  herniaire)  is  present.  However,  careful  bacteriological  and 
other  examination  should  nowadays  make  errors  of  this  kind  im- 
possible. 

5.  Peritonitis  and  Perityphlitis. — Here,  again,  the  history  is 
the  most  important,  occasionally  the  only,  aid  in  differential  diag- 
nosis. J^o  circumstance  in  the  present  or  previous  history  that  may 
have  some  connection  with  the  disease  should  be  neglected.  Thus, 
a  previous  typhoid,  hematemesis,  dysentery,  or  appendicitis  may 
clear  up  an  otherwise  obscure  case.  If  the  history  renders  no  aid, 
the  differentiation  is  very  difficult  in  cases  which  are  at  all  compli- 
cated, particularly  where  the  onset  was  not  sufficiently  observed. 
Is  there  intestinal  obstruction  only,  or  obstruction  and  secondary 
peritonitis,  or  primary  peritonitis,  and — what  is  always  pertinent  to 
etiology — what  is  the  nature  and  origin  of  the  process  in  question  ? 

Positive  differential  signs  do  not  exist,  since  mild  peritonitic 
symptoms  may  be  present  in  the  early  stages  of  intestinal  obstruc- 
tion and  thereby  lead  to  error.  By  a  consideration  of  all  the 
important  symptoms  of  both  conditions  it  will  be  easier  to  arrive  at 
a  correct  diagnosis.  These  include  fever,  sensitiveness  to  pressure, 
tympanites,  abnormal  peristalsis,  vomiting,  ascites,  and  changes  in 
the  urine. 

Ko  positive  conclusions  can  be  drawn  from  the  presence  or 
absence  of  fever.  In  diffuse  peritonitis  it  may  be  entirely  absent, 
whereas  in  intestinal  obstruction  the  fever,  when  present,  is  apt  to 
be  only  moderate.  High  fever  from  the  very  onset  (39°  C.  and 
over)  would,  in  itself,  indicate  acute,  diffuse  peritonitis. 


INTESTINAL   OBSTRUCTION  369 

The  sensitiveness  to  pressure  is  sometimes  of  diagnostic  impor- 
tance, but  may  be  absent  in  peritonitis  and  be  very  marked  in 
obstruction.  Still,  sensitiveness  to  pressure  is  generally  much  more 
accentuated  in  peritonitis  than  in  obstruction  ;  in  the  latter  it  is 
severe  only  when  peritoneal  complications  are  already  present.  The 
situation  of  the  area  of  sensitiveness  is  also  of  significance.  If  from 
the  beginning  it  has  been  localized  in  the  right  iliac  fossa  and  has 
remained  there,  the  assumption  of  a  perforative  peritonitis  follow- 
ing perityphlitis  is  much  more  probable. 

In  like  manner  the  tympanites  is  to  be  cautiously  employed 
as  a  differential  factor.  In  peritonitis,  as  in  obstruction,  it  may 
be  extensive  or  entirely  absent.  When  present  in  peritonitis  it 
soon  becomes  general.  This  is  in  sharp  contrast  to  some  forms 
of  obstruction  (strangulation)  in  which,  as  we  have  already  seen, 
meteorism  is  distinctly  localized  as  long  as  there  is  no  intestinal  paral- 
ysis. But  even  this  symptom  becomes  only  a  theoretical  distinctive 
characteristic  when  we  are  dealing  with  a  large  sacculated  peri- 
toneal exudate  which  may  produce  the  same  physical  signs  as  a 
distended  coil  of  intestine  in  obstruction. 

Well-marked,  visible,  and  palpable  intestinal  peristalsis  is  a  valu- 
able symptom  of  intestinal  obstruction,  but  unfortunately  it  is  absent 
in  the  greater  number  of  cases.  Besides,  slight  evidences  of  peri- 
staltic motion  may  easily  be  overlooked.  The  absence  of  all  intes- 
tinal motion  and  sounds  tends  to  support  the  diagnosis  of  peritonitis, 
but  even  this  is  no  convincing  proof. 

Vomiting  is  a  symptom  of  both  diseases,  and  may  make  difficult 
or  frustrate  all  differentiation.  The  early  appearance  of  fsecal  vom- 
iting speaks  rather  for  obstruction  than  for  peritonitis.  Though 
feecal  vomiting  occasionally  occurs  in  peritonitis  with  intestinal 
paralysis,  it  is  by  no  means  as  frequent  as  in  intestinal  obstruction. 
The  occurrence  of  a  fluid  exudate  is  found  in  peritonitis  as  well 
as  in  several  forms  of  intestinal  obstruction  (volvulus,  strangula- 
tion) ;  this  sign  therefore  possesses  no  differential  significance. 

The  same  is  true  of  the  amount  of  indican  in  the  urine,  which 
may  also  be  much  increased  in  acute  peritonitis.  The  absence  of 
marked  indicanuria  may,  in  connection  with  other  signs,  speak  for 
obstruction  of  the  large  intestine. 

The  greater  part  of  what  has  been  said  above  also  applies  to  peri- 
typhlitis, which  is  the  most  frequent  cause  of  perforative  peritonitis. 

It  is  evident  that  those  cases  only  ought  to  be  differentially  con- 
sidered in  which  the  clinical  picture  of  severe  intestinal  obstruc- 


370  DISEASES   OF   THE   INTESTINES 

tion  is  present.  Aside  from  the  history  of  the  case,  which  may  give 
us  valuable  information,  distinct  localized  pain  over  McBurney's 
point,  even  in  a  case  of  indirectly  developed  diifuse  peritonitis, 
moderate  resistance,  increased  rigidity,  or  oedema  of  the  abdomi- 
nal muscles,  may  indicate  the  correct  diagnosis.  Where,  as  not 
infrequently  happens,  these  data  are  absent  the  diagnosis  will  long 
be  doubtful. 

Symptomatology  and  Diagnosis  of  the  Yaeious  Kinds  of 
Intestinal  Obstruction 

I.    External  Intestinal  Obstruction  by  Bands,  Clefts, 
Fenestra,  and   Internal  Hernise 

Of  all  types  of  obstruction  the  above  variety  is  scientifically  the 
most  interesting  and  the  most  frequent,  but  unfortunately  diag- 
nostically  the  most  unfruitful.  There  are  innumerable  possibilities, 
and  it  would  require  a  monograph  to  carefully  analyze  and  discuss 
the  different  varieties  of  this  type  of  obstruction. 

We  will  therefore  content  ourselves  with  a  brief  description 
of  its  most  frequent  forms.  Since  I  have  had  but  little  experience 
with  these  various  types,  I  shall  follow  the  excellent  description 
of  Treves  ^^. 

Treves  distinguishes  five  varieties  of  external  intestinal  obstruc- 
tion. 

1.   Strangulation  hy  Isolated  Peritoneal  Adhesions 

Since  chronic  local  peritonitis  is  an  extremely  frequent  condition,  it  is 
apparent  tiiat  it  is  a  prominent  factor  in  the  etiology  of  intestinal  obstruc- 
tion. Generally  one  peritoneal  adhesion  is  jDresent  (see  Fig.  32j,  rarely  there 
are  several.  This  fact  is  of  great  surgical  importance,  for  occasionally  during 
operation  the  obstruction  is  thought  to  have  been  overcome  by  ligation  of  a  pseu- 
do-ligament, but  the  continuance  of  the  obstruction  and  autopsy  show  the  jires- 
ence  of  a  second  adhesion,  the  real  cause  of  the  constriction.  The  adhesions 
in  question  are  circular  or  in  the  form  of  strands,  and  vary  considerably  in 
length  and  thickness ;  they  vary  from  the  size  of  a  thread  to  that  of  a  finger. 
According  to  Treves,  the  average  length  is  4  to  5  centimetres.  Naturally,  every 
adhesion  which  strangulates  the  intestine  must  have  at  least  two  points  of 
attachment.  One  of  its  ends  is  very  frequently  connected  with  the  mesentery. 
In  other  cases  both  ends  are  thus  attached,  and  then  the  points  of  insertion  are 
far  apart  (see  Fig.  33,  page  371).  The  number  of  possible  attachments  is  as  large 
as  the  possible  adhesions  of  the  intestines  with  each  other  and  with  the  remain- 
ing abdominal  organs.  "There  is  scarcely  any  conceivable  combination 
of  connected  areas  which  is  not  illustrated  in  the  history  of  these  adhesions  " 
(Treves  [p.  34]). 


Fig.  32. — Strangulation  by  a  Broad  Peritoneal  Band  passing  between  Two  Adja- 
cent Coils  of  the  Ileum.     (Treves.) 


Fig.  S3. — Strangulation  of  Small  Intestine  by  a  Solitary  Band  attached  at  Either 
End  to  the  Mesentery.     (Ti-eves.) 


3Y2 


DISEASES   OP   THE   INTESTINES 


It  is  a  fundamental  observation  that  some  portion  of  the  small  intestines 
is  most  frequently  constricted,  and  that  its  most  movable  segment,  the  ileum, 
is  generally  affected. 

The  organs  from  which  the  bands  most  frequently  originate  are  the  female 
pelvic  organs  (pelvic  peritonitis)  and  the  caecum  and 
appendix.  The  number  of  possible  variations  still  in- 
creases vphen  we  consider  the  frequent  anomalous  dis- 
placements of  the  several  intestinal  segments. 

Besides  strangulation  by  isolated  peritoneal  adhe- 
sions, there  is  another  form  in  which,  because  of  peri- 
tonitis, movable  organs  become  fixed  and  thereby  give 
rise  to  obstruction.  To  this  category  belong  particu- 
larly the  vermiform  appendix,  Meckel's  diverticulum 
(see  opposite  page),  and  in  rarer  cases  the  Fallopian 
tubes,  appendices  epiploicse,  and  the  mesentery,  which 
is  changed  into  a  strand.  These  organs  form  either 
a  band  or  an  arch  under  which  the  intestine  becomes 
constricted,  or  they  form  a  coil  in  which  a  portion  of 
the  bowel  is  caught.  The  first  is  the  more  frequent 
occurrence  (see  Fig.  34). 


Fig.  84. — Strangtxlation 
OF  A  Small  Intestinal 
Coil  by  a  Long  Liga- 
mentous Strand. 


practical 
omentum 


2.  Strangulation  through  Clefts  and  Fenestra 

This  type  of  obstruction  is  rare  and  hence  possesses  only  slight 
importance.  Clefts  and  fenestra  are  found  most  frequently  in  the 
and  mesentery.  They  may  be  congenital,  but 
are  generally  produced  by  trauma  or  by  peri- 
toneal inflammatory  products,  or  they  consist 
of  spaces  which  have  been  formed  by  peri- 
toneal adhesions  between  different  organs  (uter- 
us, ovaries,  hernial  canals,  appendices  epi- 
ploicse,  etc.). 

Discussion  of  the  several  forms  and  varieties 
is  not  appropriate  to  the  scope  of  this  work  ;  we 
therefore  refer  to  the  thorough  descriptions  of 
Treves  ^^  and  Leichtenstern  \ 

3.  Strangulation  hy  Omental  Bands 

As  strands  are  caused  by  peritonitis,  so  bands 
may  also  develop  from  inflammation  of  the 
mesentery.  The  latter  (mesenterial  bands)  are 
much  larger  in  size  than  the  former  (see  Figs. 
34  and  35).  They  originate  from  traumatism, 
pelvic  peritonitis,  or,  in  the  majority  of  cases, 
from  peritonitis  about  a  hernial  sac,  especially 
femoral  hernia.  The  left  side  is  more  apt  to 
be  involved  because  the  omentum  generally  lies 
in  that  half  of  the  abdomen,.  As  with  peritoneal  adhesions,  so  two  or  more 
mesenteric  ligaments  may  be  present. 


Fig.  35. — Internal  Strangula- 
tion of  an  Intestinal  Coil 
BY  A  Strand  passing  from 
THE  Omentum  or  Transverse 
Colon  to  the  Anterior  Ab- 
dominal Wall.     fKönig.) 


INTESTINAL   OBSTRUCTION 


373 


4.  Strangulation  ty  MecTceVs  Diverticulum 

As  is  known,  Meckel's  diverticulum  is  due  to  a  pervious  or  an  incompletely 
obliterated  omphalomesenteric  duct.  The  abdominal  end  of  the  diverticu- 
lum is  generally  free ;  only  rarely  is  it  adherent  to  the  umbilicus  as  a  solid  strand 
or  pervious  canal.  It  is  evident  that  free  mobility  of  the  diverticulum  is 
the  most  frequent  cause  of  knotting  and  volvulus, 
but  it  sometimes  forms  a  bridge  under  which 
intestines  become  incarcerated.  This  type  of 
strangulation  is  generally  the  result  of  fixation  of 
the  diverticulum  by  peritonitis.  The  diverticu- 
lum is  usually  adherent  to  the  mesentery,  but  it 
may  also  adhere  to  other  portions  of  the  intes- 
tines, the  omentum,  caecum,  small  intestines,  or  to 
the  pelvic  organs,  thereby  possibly  causing  intestinal 
incarceration. 

When  the  diverticulum  is  abnormally  long  and 
has  a  kind  of  club-shaped  swelling  at  its  free  end, 
a  not  infrequent  type  of  obstruction  may  occur. 
The  diverticulum  may  form  a  sort  of  slipknot  in 
which  the  ampulla,  being  the  thicker  portion,  tends 
to  tighten  the  knot  (hence  called  by  the  French 
^'■clef  de  Vetranglemenf'')  (see  Fig.  36).  We  j)ass 
over  several  other  forms  of  obstruction  which 
are  described  by  Treves,  as  they  are  more  infre- 
quent. 


Fig.  36. — Internal  Strangu- 
lation OF  A  Loop  of 
Small  Intestine  by  a 
Meckel's     Divektioulum 

COILED    about   it. 

a,  attachment  of  the  divertic- 
ulum to  the  intestine,  i, 
its  club-shaped  end  (Eeg- 
nault-Beclard). 


5.  Strangulation  from  Internal  Hernice, 

According  to  Leichtenstern,  internal  hernise  are  those  which  lie  either  en- 
tirely within  the  abdominal  or  thoracic  cavities,  or  which  are  situated  retro-  or 
subperitoneally,  parallel  to  the  abdominal  wall  and  protrude  into  the  abdomi- 
nal cavity,  but  never,  even  by  continued  growth,  appear  externally. 

By  external  hernise  we  mean  those  which  push  the  peritoneum  in  an  exter- 
nal direction,  and  which,  by  continued  growth,  become  externally  visible 
tumours.  Leichtenstern,  who  has  given  us  the  most  thorough  description  of 
this  subject,  distinguishes  three  forms  : 

1.  Very  small,  external  hernise,  which,  particularly  in  fat  individuals,  may 
remain  latent  throughout. 

2.  Interstitial  herniae  which  run  their  course  under  the  clinical  picture  of 
an  internal  hernia.  They  originate  from  the  different  hernial  canals,  most  fre- 
quently from  the  inguinal.  They  occur  either  alone  or  in  connection  with 
external  inguinal  or  femoral  hernise,  whose  subsidiary  swelling  they  represent. 
Interstitial  herniae  are  generally  the  result  of  taxis  and  efforts  at  reduction. 
Interstitial  incarceration  has  often  been  observed  in  the  presence  of  mobility  of 
the  main  hernia. 

3.  Finally,  the  following  very  rare  herniae — important  only  surgically  and 
anatomically — run  the  course  of  the  internal  herniae,  viz.,  obturator,  sciatic, 
perineal,  rectal,  vaginal,  and  lumbar  herniae. 

35 


374  DISEASES   OF  THE  INTESTINES 

With  the  exception  of  diaphragmatic  hernia,  true  "internal  hernise  "  can 
hardly  ever  be  diagnosticated.  We  therefore  limit  ourselves  to  the  mention  of 
their  names,  and  again  refer  to  the  exemplary  description  of  Leichtenstern.  This 
author  gives  the  following  varieties  of  true  internal  hernia :  hernia  retro-peri- 
tonealis  anterior  (hernia  intra-iliaca,  ante-vesicalis,  retro-pubica,  hernia  interna 
vaginalis  testiculi,  hernia  iliaco  sub-f ascialis) ,  hernia  duodeno-jejunalis  (Treitz's 
hernia,  of  which  about  50  cases  have  been  described),  hernia  pericsecalis,  hernia 
intersigmoidea,  hernia  intra-epiploica,  hernia  ligam.  uteri  lati,  hernia  fora- 
men Winslowii,  and,  finally,  hernia  diaphragmatica. 

There  are  two  forms  of  diaphragmatic  hernia,  the  true  and  the  false.  The 
former  name  is  applied  to  those  cases  in  which  an  abdominal  organ  or  organs 
have  entered  the  pleural  cavity  through  an  opening  in  the  diaphragm,  and 
which  have  as  hernial  covering  either  pleura  or  peritoneum,  or  both.  The  latter 
name  (false)  is  applied  to  those  cases  in  which  the  abdominal  viscera  pass  through 
an  opening  both  of  the  diaphragm  and  of  the  contiguous  serous  membranes 
(pleura  and  peritoneum),  the  abdominal  organs  coming  into  direct  contact  with 
the  thoracic.  Such  visceral  displacements  must  be  looked  upon  rather  as  a 
prolapse  or  ectopia  than  as  a  true  hernia.  Most  diaphragmatic  hernise  are 
"false."     Of  254  cases,  only  38  were  true. 

Entrance  of  the  abdominal  viscera  into  the  chest  cavity  is  caused  either  by 
congenital  defects  of  the  diaphragm,  by  a  physiologically  preformed  fenestrum, 
or  by  an  absence  of  continuity  in  the  diaphragm  from  inflammation  or  (more 
often)  traumatism. 

Congenital  defects  occur  most  frequently  in  the  muscular  portion  of  the 
diaphragm,  usually  to  the  left  side  (in  the  proportion  of  98  to  19),  and  occa- 
sionally extend  over  an  entire  half  of  the  diaphragm.  Acquired  diaphragmatic 
hernife  are  also  generally  leftsided ;  the  place  of  entrance  is  more  frequently  in 
the  posterior  than  in  the  anterior  portion  of  the  midriff. 

The  preformed  openings  in  the  diaphragm  which  may  give  rise  to  hernige 
are  (1)  the  esophageal  opening ;  (2)  the  foramen  of  Morgagni  (in  that  portion 
of  the  midriff  corresponding  to  the  sternum  and  the  seventh  costal  cartilage  of 
either  side);  (3)  the  foramen  of  Bochdalek  (posteriorly  between  lumbar  and 
costal  division  of  the  diaphragm) ;  (4)  the  point  of  entrance  for  the  sympa- 
thetic nerve  (between  the  external  and  median  crura). 

The  abdominal  viscus  most  frequently  displaced  is  the  stomach;  then  follow 
the  transverse  colon,  omentum,  small  intestines,  spleen,  liver,  pancreas,  and 
kidney.  The  greater  curvature  of  the  stomach  is  regularly  found  uppermost, 
and  the  lesser  curvature  below.  If  the  fundus  alone  be  involved,  and  not  the 
pylorus,  volvulus  with  incarceration  of  the  stomach  may  follow.  Two  or  more 
organs  are  generally  displaced.  When  only  one  viscus  is  displaced  it  is  usually 
the  stomach,  less  frequently  the  colon,  small  intestine,  or  omentum.  Most 
cases  of  diaphragmatic  hernia  are  accidentally  discovered  at  the  autopsy.  They 
sometimes  produce  significant  symptoms,  which  under  favourable  circumstances 
may  lead  to  a  diagnosis  during  life.  Leichtenstern  •**,  who  first  successfully  recog- 
nised a  case  of  diaphragmatic  hernia,  considers  that  the  diagnosis  may  be  made 
if  pneumothorax  can  be  excluded,  and  if  it  can  be  proved  that  there  are  in  the 
thoracic  cavity  other  air-containing  organs,  which  upon  auscultation  and  per- 
cussion present  differences  depending  upon  their  varying  conditions  of  fulness. 


INTESTINAL   OBSTRUCTION  375 

Filling  up  the  stomach  or  colon  with  air  or  water  may  aid  the  diagnosis.  Dis- 
placement of  the  heart  to  the  right  is  also  of  diagnostic  significance  (P.  Gutt- 
mann^^  and  Abel  ^^).  Finally,  trans-illumination  of  the  stomach,  particularly, 
its  radiograph  (by  the  introduction  of  a  soft  metallic  sound),  ought  to  make 
diagnosis  possible. 

Symptomatology 

Before  discussing  the  individual  symptoms  of  these  forms  of  ob- 
struction we  must  mention  several  facts  of  great  practical  impor- 
tance. 

First  of  all  as  to  the  seat  of  incarceration.  In  the  overwhelming 
number  of  cases  the  ileum  is  the  segment  affected ;  the  other  intes- 
tinal segments,  both  above  and  below  the  ileum,  are  so  rarely  affected 
that  they  hardly  come  up  for  consideration.  The  cause  of  this  fre- 
quency of  ileal  incarceration  lies  in  its  anatomical  position,  and  in 
the  possibility  of  its  coming  into  contact  with  all  those  other  organs 
which  are  most  apt  to  be  incarcerated  (mesentery,  great  omentum, 
Meckel's  diverticulum,  vermiform  appendix,  pelvic  organs,  hernial 
canals,  etc.). 

The  age  requires  consideration.  Though  incarceration  may  occur 
at  all  ages,  yet  statistics  show  that  it  is  essentially  a  disease  of  early 
life,  that  it  is  most  frequent  in  the  second  decade,  and  that  it  occurs 
only  exceptionally  in  the  later  periods,  or  in  the  first  decade. 

Sex  is  also  a  factor,  though  the  difference  in  this  particular  is 
not  sufficiently  marked  to  allow  of  positive  data  to  be  based  there- 
upon. In  women  the  puerperium  and  the  diseases  incidental  thereto 
are  considered  as  predisposing  factors.  We  find  that  appendix 
affections,  hernise,  traumatism,  and  Meckel's  diverticulum  act  more 
frequently  as  predisposing  factors  in  the  male  than  in  the  female,  so 
that  the  proportion  of  incarcerations  is,  according  to  Leichtenstern, 
180  males  to  118  females. 

In  its  important  details  the  clinical  picture  of  incarceration  coin- 
cides with  that  already  given  under  general  symptomatology.  While 
referring  to  the  latter  we  again  point  out  certain  important  symp- 
toms which  are  particularly  prominent  in  the  clinical  ensemhle.  Thus 
we  would  mention  the  acute  onset  in  the  midst  of  normal  health  or 
after  a  slight  illness,  or  occasionally  after  a  traumatism,  the  violent 
development  of  symptoms  finally  leading  to  death,  the  severe  pain, 
the  vomitus  rapidly  becoming  feculent,  the  complete  retention  of 
stool  and  gases  and  contrasting  strangely  with  the  absence  or  only 
slight  presence  of  meteorism,  the  retention  of  urine,  rapidly  in- 
creasing  debility,  collapse   amid  complete    consciousness,  and  the 


376  DISEASES  OF   THE   INTESTINES 

absence  of  fever  when  the  case  is  not  complicated  by  peritonitis. 
The  few  exceptions  to  this  type  are  characterized  by  a  less  violent 
development  of  symptoms.  The  course  of  the  disease  may  be  less 
sudden  and  show  deceptive  remissions.  These  differences  mainly 
depend  npon  the  form  and  degree  of  the  obstruction. 

Diagnosis 

jS^ot  only  the  presence  of  an  incarceration  or  strangulation,  but 
also  its  location  and  nature  must  be  determined.  Occasionally, 
favourable  circumstances — a  history  which  points  directly  to  the 
source  of  obstruction — allow  of  a  correct  diagnosis  being  made, 
but  in  the  large  majority  of  cases  the  diagnosis  is  impossible.  If 
we  have  diagnosticated  internal  strangulation,  we  may  assume  the 
site  of  the  obstruction  to  be  in  the  lower  ileum,  since  that  portion 
is  more  frequently  involved.  Regarding  the  differentiation  of  this 
(internal)  from  other  forms  of  obstruction,  we  shall  only  mention 
the  most  important  points  which  enable  us  to  recognise  the  condi- 
tion in  favourable  cases  :  early  period  of  life,  a  history  of  inflam- 
matory processes  in  the  abdominal  cavity  or  of  the  pelvic  vis- 
cera, previous  traumatism,  previous  laparotomy,  very  acute  onset  of 
severe  symptoms,  absence  of  tumour,  absence  of  marlied  mete- 
orism^  the  jyresence  of  a  fixed,  inflated  coil  of  intestine  and  per- 
haps visihle  peristalsis,  hemorrhagic  exudate,  and  the  absence  of 
bloody  stools.  (Compare  in  this  connection  the  differential  diag- 
nosis, page  407.)  When  the  case  is  comphcated  by  peritonitis  the 
diagnosis,  as  a  rule,  cannot  be  made. 

II.   Volvulus 

Preliminary  Observations. — By  volvulus  we  understand  a  tor- 
sion of  the  intestine  about  its  mesenteric  axis,  or  the  knotting  to- 
gether of  two  coils  of  gut.  We  must  consider  volvulus  of  the 
sigmoid  flexure  (the  most  frequent  and  practically  the  most  impor- 
tant form),  volvulus  of  the  ascending  colon,  and  volvulus  of  the 
small  intestine. 

"Volvulus  of  the  sigmoid  flexure  is  found  in  two  thirds  of  all  the 
cases,  and  occurs  when  the  sigmoid  is  very  long,  and  its  mesocolon 
long  and  narrow,  so  that  the  ends  of  the  arch  are  brought  nearer  to 
each  other  (see  Fig.  37).  It  is  quite  apparent  that  under  such  con- 
ditions volvulus,  with  the  mesentery  as  the  axis,  may  easily  occur. 

The  causes  of  volvulus  are  direct  and  indirect  (predisposing). 
Of  the  latter  the  following  may  be  mentioned :    congenital  predis- 


INTESTINAL  OBSTRUCTION 


377 


i 
% 


)L 


position  (an  abnormally  long  sigmoid  with  a  long,  narrow  mesen- 
tery), habitual  constipation,  a  purely  vegetable  diet  (which,  accord- 
ing to  Lingen  and  Küttner,  explains  the  frequency  of  volvulus  in 
the  peasants  of  Eussia),  and  peritoneal  inflammation  in  the  neigh- 
bourhood of  the  sigmoid  flexure,  with 
consequent  cicatrization  of  its  mes- 
entery (mesenteritis,  see  page  394). 
Trauma,  marked  natural  or  artificial 
intestinal  peristalsis  or  its  reverse, 
acute  intestinal  paresis,  errors  of 
diet,  foreign  bodies,  gallstones,  dys- 
entery with  consequent  cicatrices, 
tumours,  laparotomies,  etc.,  are  di- 
rect causes  of  volvulus.  Undoubt- 
edly f secal  impaction  is  the  most  fre- 
quent cause  of  volvulus.  It  occasions 
a  sinking  of  the  upper  limb  of  the 
sigmoid  flexure  upon  the  lower,  or 
the  lower  limb  gradually  approaches  the  upper  till  finally  the  volvu- 
lus is  completed  by  severe  peristalsis,  induced  perhaps  by  a  strong- 
drastic  purge.  In  most  cases  there  is  a  torsion  of  180  degrees,  more 
rarely  of  360  degrees.  The  torsion  takes  place  about  the  mesenteric 
axis,  and  also,  to  some  extent,  about  its  [intestine]  own  axis.    In  these 


V. 


-^ 


f§ 


iii\ 


Fig.  37. — Sigmoid  Flexure  showing  a 
Tendency  to  Volvulus  Forma- 
tion.     [Treves.] 


Fig. 


Type  Eectum  en  Arriere.     (Potain.) 


Type  Eectum  en  Avant.     (Potain.) 


cases  either  the  descending  colon  lies  in  front  of  the  rectum  (type 
rectum  en  arriere,  Potain),  or  the  rectum  lies  in  front  of  the  colon 
(type  rectum  en  avant)  (see  Fig.  38,  A,  B).     The  former  type  is  by 


378  DISEASES   OF   THE  INTESTINES 

far  the  more  frequent.  If  the  volvulus  be  complete  (i.  e.,  torsion  of 
270  to  360  degi-ees),  spontaneous  untwisting  is  impossible,  because 
of  the  changes  which  soon  occur  in  the  affected  limb  of  the  sigmoid 
flexure  (accumulation  of  blood,  exudation,  formation  of  gas),  and 
in  that  lying  above  it  (intense  meteorism,  intestinal  paresis).  Ac- 
cording to  experhnents  of  Melchioris  ^'^,  the  resistance  of  the  abdomi- 
nal wall  also  prevents  untwisting.  Finally,  peritonitis  will  contrib- 
ute to  the  fixation  of  the  volvulus.  Spontaneous  untwisting  may 
follow  incomplete  volvulus. 

As  already  stated,  volvulus  of  the  other  segments  of  the  large 
intestine  (csecum,  transverse  colon)  is  extremely  rare.  The  condi- 
tions under  which  it  occurs  are  similar  to  those  of  volvulus  of  the  sig- 
moid.   Somewhat  more  frequent,  though  still  quite  rare,  is  volvulus 

of  siuD'le  or  several  coils  of  small  intestine.     The  amount  of  torsion 

o 

is  generally  about  180  degrees.  Usually  the  upper  end  of  the  small 
intestine  lies  below  and  to  the  left,  and  the  lower  end  above  and  to 
the  right.  The  intestines  and  mesentery  lying  to  the  right  are 
transposed  to  the  left,  and  mce  versa.  The  intestinal  obstruc- 
tion need  not  be  complete.  Yolvulus  of  this  kind  occurs  even  in 
earliest  childhood.  According  to  Leichtenstern  ^,  congenital  mal- 
formation of  the  mesentery,  in  which  ileum,  csecum,  and  ascending 
colon  have  a  common  mesentery,  seems  particularly  to  predispose 
to  volvulus.  Yolvulus  of  the  small  intestine  occurs  most  fre- 
quently in  coils  which  have  for  a  long  time  been  either  in  a  large 
hernial  sac  or  in  its  vicinity,  or  which  have  become  adherent  to  pel- 
vic viscera  (Leichtenstern). 

We  have  mentioned  that  the  volvulus  usually  occurs  about  the 
mesenteric  axis  of  the  bowel.  Besides  this  there  is  a  true  torsion 
about  the  intestinal  axis  ;  such  cases  generally  affect  the  large  intes- 
tines, particularly  the  csecum  and  ascending  colon.  Leichtenstern 
considers  most  of  them  as  kinking  following  displacements.  These 
volvuli  need  not  produce  complete  obstruction  ;  this  may  only  occur 
when  other  changes  are  superadded — for  example,  when  the  mesen- 
tery of  a  coil  of  small  gut  is  thrown  across  the  place  of  kinking. 

Finally,  we  must  briefly  describe  the  knotting  together  of  two 
intestinal  coils.  The  sigmoid  flexure  and  the  ileum  are"  most  often 
twisted  about  each  other  (see  Fig.  39).  Much  more  rarely  there  is 
knotting  or  coiling  together  of  small  intestine,  or  a  twist  of  the  jejuno- 
ileum,  csecum,  and  ascending  colon.  In  the  first-mentioned  instance, 
according  to  Leichtenstern,  the  most  frequent  occurrence  is  the  dis- 
placement of  small  intestine  across  the  narrow  mesentery  of  the 


INTESTINAL   OBSTRUCTION 


579 


sigmoid.  Througli  the  space  which  is  thus  formed  bj  the  posterior 
abdominal  wall  and  the  roots  of  the  crossed  coil  of  small  intestine 
and  sigmoid  flexure,  the  superior 
portion  of  the  sigmoid  enters,  after 
passing  from  below  upward  in  front 
of  the  small  intestine.  The  clinical 
course  of  this  knot  formation  is 
exceedingly  acute ;  it  is  fatal  in 
one  or  two  days.  Such  forma- 
tions are  frequently  ushered  in  by 
violent  diarrhoeas,  which  may  re- 
main pronounced  throughout  the 
course  of  the  disease,  to  which  they 
lend  a  certain  similarity  to  cholera.       '^'  %    If^^F  )        III!  I    h  f  ^  J 

Symptomatology 


Fig.  39. — Schematic  Drawing  to  il- 
lustrate A  Knotting  Together  of 
Ileum  (/)  and  Sigmoid  Flexure  {S). 
B,  rectum.     (Leiehtenstern.) 


In  what  follows  we  shall  de- 
scribe more  especially  the  clinical 
symptoms  of  sigmoid  volvulus.  Be- 
cause of  their  rarity  and  the  ob- 
scurity of  their  symptoms  the  other 
forms  have  but  little  clinical  interest,  and  will  be  very  briefly  de- 
scribed at  the  end  of  this  section.  According  to  most  clinicians, 
volvulus  is  a  disease  of  late  life  (forty  to  sixty  years).  In  20  cases 
Treves  ^^  found  the  average  age  forty-nine  years.  In  his  statistics 
Leiehtenstern  ^  found  only  one  case  in  the  first  decade.  Men  seem 
to  be  more  predisposed  to  this  affection  than  women  ;  Treves  gives 
the  proportion  as  4  to  1.  The  occurrence  of  volvulus  late  in  life 
is  explained  by  the  fact  already  mentioned  (page  3YY),  that  it 
develops  most  frequently  in  connection  with  habitual  constipa- 
tion, which  is  most  severe  in  the  fourth  to  the  sixth  decades  of 
life.  In  view  of  the  fact  that  obstinate  constipation  is  so  frequent 
in  women,  it  is  rather  striking  that  the  majority  of  cases  of  volvulus 
should  occur  in  men.  Perhaps  more  extensive  statistics  will  show 
that  the  female  sex  is  after  all  more  prone  to  this  affection. 

Except  for  occasional  acute  attacks,  the  varieties  of  intestinal 
obstruction  already  described  generally  present  no  evidences  of 
previous  intestinal  disease ;  chronic  constipation  really  forms  the 
initial  stage  of  an  affection  which  finally  ends  with  an  attack  of 
volvulus. 

The   pernicious   character  of   the   constipation  is  often  appar- 


380  DISEASES   OF   THE  INTESTINES 

ent  from  the  history.  The  constipation  increases  steadily,  and 
increasing  doses  of  drastic  purges  produce  only  incomplete  evacua- 
tions of  a  spastic  or  diarrhoeal  character,  accompanied  by  severe  pain 
and  perhaps  by  nausea  and  vomiting.  After  a  longer  or  shorter 
period  volvulus  suddenly  occurs. 

As  in  other  varieties  of  intestinal  obstruction,  the  main  symp- 
toms are  pain,  vomiting,  complete  intestinal  occlusion,  disturbance  of 
general  health.  Excepting  that  they  are  less  violent,  all  these  symp- 
toms differ  but  little  from  those  of  obstruction  of  the  small  bowel. 

Pain,  the  first  and  most  striking  symptom,  is  quite  marked,  but 
is  not  so  severe  or  continuous  as  in  incarceration  or  strangulation. 
It  is  intermittent,  and  is  relieved  by  small  doses  of  opium.  The 
patient  may  be  able  to  obtain  sleep  without  narcotics,  and  other- 
wise present  a  certain  euphoria.  The  pain  is  usually  most  pro- 
nounced about  the  umbilicus,  more  rarely  it  is  found  in  the  vicinity 
of  the  sigmoid  itself.  Tenesmus  may  accompany  the  pain,  but  even 
in  well-defined  cases  of  volvulus  it  may  be  absent.  If  peritonitis 
sets  in,  the  pain  is  increased  and  becomes  more  diffuse. 

Sensitiveness  to  pressure  may  be  absent  in  the  beginning  of  the 
affection ;  later,  the  tenderness  becomes  easily  demonstrable,  and 
is  generally  localized  in  the  umbilical  region.  Marked  increase 
in  the  degree  and  area  of  this  sensitiveness  to  pressure  is  always  a 
suspicious  sign  of  beginning  peritonitis. 

In  the  beginning,  the  vomiting  is  reflex  and  accompanies  the 
paroxysms  of  pain.  Occasionally  vomiting  is  entirely  absent,  and 
then  nausea  or  severe  explosive  eructations  occur,  followed  by 
momentary  relief.  The  vomitus  is  by  no  means  very  copious  ;  at 
first  it  consists  of  the  stomach  contents  mixed  with  mucus,  later, 
of  grayish  green  or  brownish  masses  with  a  slight  "  intestinal  odour." 
As  stated  by  Treves,*  the  vomiting  is  veiy  rarely  stercoraceous. 
If  in  the  presence  of  well-defined  symptoms  stercoraceous  vomit- 
ing occurs  quite  early,  it  always  indicates  an  unfavourable  termi- 
nation of  the  disease. 

As  in  the  other  forms  of  intestinal  obstruction,  anorexia  and 
very  severe  thirst  occur  also  in  volvulus. 

Usually,  from  the  very  beginning  of  the  disease  neither  faeces 
nor  flatus  are  passed.  Small  quantities  of  fsecal  masses  come  away 
with  the  enemata  or  rectal  irrigations,  but,  as  already  mentioned, 
no  flatus  accompanies  such  evacuations.     If  purges  or  enemata  do 

[*  Loc.  cit,  p.  299.] 


INTESTINAL   OBSTRUCTION  381 

produce  stools  accompanied  bj  flatus,  incomplete  volvulus  should 
be  suspected.  A  single  evacuation  of  this  kind  should  not  make 
the  physician  too  sanguine,  for  experience  has  shown  that  an  incom- 
plete volvulus  may  readily  become  complete  through  peristalsis. 
Therefore  the  general  condition  of  the  patient  is  more  significant 
than  the  condition  of  the  stool.  Occasionally  blood  has  been  found 
in  the  evacuations. 

Local  tympanites  is  a  very  important  and  characteristic  symp- 
tom of  volvulus  of  the  sigmoid ;  in  no  other  form  of  intestinal 
obstruction  is  this  symptom  so  prominent  from  the  very  beginning 
of  the  disease.  The  meteorism  is  not  limited  to  the  neighbourhood 
of  the  sigmoid  flexure ;  on  the  contrary,  this  latter  region  is  gener- 
ally occupied  by  coils  of  small  intestine.  As  previously  mentioned 
(page  23),  the  tympanites  extend  toward  the  right  in  front  and 
upward.  Curschmann^  has  made  the  important  observation  that 
in  this  disease  one  may  find  tympanitic  intestinal  coils  over  the 
entire  abdomen,  but  not  at  the  site  of  the  volvulus — i.  e.,  in  the 
vicinity  of  the  sigmoid.  Here  von  Wahl's  symptom  of  distended 
intestinal  coils  may  be  very  well  demonstrated  (page  363).  If 
peritonitis  develops,  the  meteorism  gradually  becomes  general,  and 
it  is  then  impossible  to  determine  the  location  of  the  volvulus. 
When  the  meteorism  is  moderate,  w^e  may,  in  the  lower  abdomen, 
at  or  to  the  right  of  the  median  line,  occasionally  palpate  a  resil- 
ient tumour  having  the  resistance  of  a  tightly  distended  air  cushion. 
The  tumour  usually  extends  from  the  lower  left  side  upward  toward 
the  right  hypochondrium ;  there  may  be  tympanitic  or  metallic 
tinkling  on  percussion,  but  there  may  also  be  dulness  if  the  sig- 
moid flexure  is  very  edematous,  or  contains  large  quantities  of  faeces. 

Yisible  peristalsis  is  rarely  observed.  Treves  noticed  this 
phenomenon  twice  in  20  cases.  Incomplete  occlusion  is  probably 
present  in  such  cases. 

In  volvulus  of  the  sigmoid  flexure  the  general  condition  of  the 
patient  also  sufl;ers  ;  the  reaction,  however,  is  not  as  severe  as  in 
obstruction  of  the  small  intestine.  The  pulse  remains  of  good 
quality  for  a  long  time,  and  is  not  immoderately  frequent,  the  face 
does  not  bear  that  collapsed  expression  (facies  hippocratica)  that  is 
seen,  for  instance,  in  strangulation  of  the  small  intestine.  In  one 
of  my  cases,  a  woman  of  sixty-four  years,  three  days  after  the  onset 
of  symptoms  of  obstruction,  the  patient  was  able  to  descend  two 
flights  of  stairs  without  apparent  effort.  If  diffuse  peritonitis  or 
perforation  occurs,  the  symptoms  very  rapidly  change. 


382  DISBASES  OF   THE  TNTESTINES 

The  clinical  picture  of  volvulus  of  other  segments  of  the  large 
intestine,  and  of  the  small  intestine,  is  somewhat  different  from  that 
of  the  sigmoid  flexure.  For  example,  in  volvulus  of  the  upper  por- 
tion of  the  large  bowel,  both  tenesmus  and  bloody  evacuations  are 
absent  and  the  pain  extends  more  toward  the  back.  In  volvulus  of 
the  small  bowel,  on  the  other  hand,  the  segment  below  the  point 
of  constriction  may  contain  intestinal  contents,  and  these  may  be 
evacuated.  A  case  described  by  Naunyn*  was  characterized  by 
the  passage  of  large  quantities  of  unaltered  blood.  The  mete- 
orism  naturally  is  variously  localized.  A  case  of  Nothnagel's  f  dem- 
onstrates that  the  course  of  the  disease  is  not  necessarily  violent,  and 
may  for  a  time  appear  favourable. 

Diagnosis 

In  diagnosticating  volvulus  of  the  sigmoid  flexure,  the  history 
and  the  subjective  and  objective  symptoms  require  consideration. 

The  history  will  give  valuable  data.  It  informs  us  regarding  the 
existence  of  long-standing  chronic  constipation,  and  perhaps  also 
of  a  former  incomplete  attack  of  volvulus  of  the  sigmoid  flexure. 

The  subjective  symjytoras  to  be  considered  are  the  pain,  the 
vomiting,  the  complete  intestinal  obstruction,  and  the  general  con- 
dition of  the  patient.  These  have  all  been  already  described.  Col- 
lectively they  indicate  an  intestinal  obstruction.  The  manner  of 
their  occurrence,  which,  as  already  mentioned,  is  characterized  by 
a  certain  benignancy  and  slow  development,  offers  serviceable  hints 
regarding  the  nature  and  the  seat  of  the  obstruction. 

The  most  important  objective  sign  is  local  tympanites.  If  well 
developed,  if  the  sigmoid  flexure  can  be  differentiated  from  other 
intestinal  coils  by  auscultatory  percussion,  if  the  distended  sigmoid 
flexure  can  be  grasped  and  distinctly  palpated,  and  if  the  other  symp- 
toms above  mentioned  are  present,  the  diagnosis  is  generally  assured. 
If  only  small  quantities  of  air  or  water  can  be  injected  into  the  rec- 
tum, and  these  are  immediately  returned,  the  diagnosis  is  made  still 
more  certain.  On  the  other  hand,  as  Treves  correctly  observes,  the 
possibility  of  large  quantities  of  injected  water  being  retained  by  the 
lowest  bowel  segment  by  no  means  militates  against  occlusion  of  the 
sigmoid  flexure.  It  seems  to  me  important  also  that  injections  of 
large  quantities  of  water  cannot  produce  splashing  sounds  in  the 
caecum  or  transverse  colon.     In   the   presence   of   severe   general 

*  Loc.  cit.,  p.  110.  f  Loc.  cit.,  p.  351. 


INTESTINAL  OBSTRUCTION 


383 


tympanites  tlie  demonstration  of  splashing  sounds  in  the  caecum 
may  not  be  possible,  even  though  the  sigmoid  flexure  be  pervious. 

The  indican  test  may  be  used  as  a  diagnostic  aid.  Indican, 
if  absent,  or  present  only  in  very  small  quantities,  speaks  for  ob- 
struction of  the  large  bowel.  Free  hemorrhagic  fluid  has  some- 
times been  found  in  operations  for  volvulus,  but  with  marked  tym- 
panites its  recognition  is  extremely  difiicult. 

It  is  seldom  possible  to  diagnosticate  volvulus  of  the  upper  seg- 
ments of  the  large  or  of  the  small  intestine. 

III.    Invagination,   Intussusception 

Preliminary  Remarhs. — Invagination  is  a  condition  in  which 
a  portion  of  the  intestine  is  pushed  or  inverted  into  the  lumen  of 
that  adjoining.  Thus,  three  tubes  are  telescoped  into  one  another 
(see  Fig.  40).  The  outer  tube  is  termed  the  intussuseipiens  or 
sheath,  and  the  two  inner, 
which  are  generally  full  of 
folds,  the  intussusceptum  or 
invaginatum.  The  latter  is  di- 
vided into  the  returning  (exter- 
nal) and  the  entering  (internal) 
tubes.  The  entering  tube  lies 
against  the  sheath  at  the 
"neck"  of  the  invagination 
and  is  continuous  with  the  re- 
turning tube  at  the  lower  (free) 
end  of  the  intussusceptum. 
The  point  of  junction  of  the 
two  internal  layers  is  known 
as  the  apex.  Its  relation  to 
these  layers  is  fixed  ;  with  them 
it  always  advances  farther  into 
the  intussuseipiens.  The  mu- 
cous surfaces  of  the  outer  and 

middle  tubes  and  the  serous  surfaces  of  the  inner  and  middle  tubes 
are  opposed  to  each  other.  The  mesentery  of  the  gut  is  invagi- 
nated  with  it,  and  since  the  mesentery  is  compressed  and  dragged 
upon  by  the  outer  layer,  the  intussusceptum  becomes  concave  at  its 
mesenteric  border,  and  hence  is  pulled  eccentrically,  and  not  axially, 
toward  the  intussuseipiens. 

Besides  the  ordinary  forms,  double,  or  more  rarely  triple,  invagi- 


FiG.  40. — Schematic  Drawing  to  illustrate  a 
Simple  Intestinal  Invagination. 


384  DISEASES   OF   THE   INTESTINES 

nation,  occurs.  In  the  former  there  are  five,  in  the  latter  seven,  intes- 
tinal tubes.  It  is  necessary  also  to  make  a  distinction  between  com- 
plete and  incomplete  invagination.  In  the  incomplete  form  only  a 
single  portion  of  the  intestinal  wall  projects  into  the  lumen.  Partial 
invaginations  are  sometimes  found  when  tumours  (generally  benign 
in  character)  drag  one  or  more  coats  of  the  intestines  after  them. 
As  observations  of  Böttcher  ®  and  Fleiner^'^  have  shown,  invagi- 
nations incomplete  at  the  outset,  may  finally  become  complete. 
Several  years  ago  I  observed  a  partial  intussusception  in  a  success- 
fully operated  case  of  cancer  of  the  csecum.  Besides  simple  invagina- 
tion, D'Arcy  Power,  Birch- Hirschfeld,  and  Thomas  have  described 
cases  in  which  two  intussusceptions  were  present  in  different  por- 
tions of  the  bowel.     Such  a  condition  is,  however,  extremely  rare. 

From  an  etiological  standpoint  we  must  distinguish  two  different 
types  of  invagination  :  the  physiological  and  the  pathological  (Noth- 
nagel), or  the  agonal  and  the  vital  (inflammatory)  forms  (Leichten- 
stern). 

The  first  variety  very  probably  occurs  immediately  preceding 
death.  At  that  time  one  intestinal  segment  may  lose  its  power  of 
contracting  before  another ;  when  an  adjoining  portion  of  the  bowel 
then  contracts  an  invagination  of  the  second  part  into  the  lumen  of 
that  ah-eady  paralyzed  may  take  place.  This  form  of  invagination 
occurs  almost  entirely  in  the  small  intestine.  There  may  be  more 
than  one  such  invagination.  They  occur  more  frequently  in  children 
than  in  adults,  and  are  found  both  in  an  ascending  and  a  descending 
direction.  They  are  further  distinguished  from  the  pathological 
variety  by  the  fact  that  the  mesentery  is  never  drawn  into  the  in- 
vagination.    This  form  cannot  be  diagnosticated  before  death. 

In  contradistinction  to  the  above  variety,  vital  or  pathological 
invagination — the  only  form  which  is  of  practical  importance — is 
generally  single  and  often  of  considerable  size.  The  invagination 
is  almost  always  in  a  descending  direction  (Leichtenstern  found  only 
8  ascending  invaginations  in  593  cases),  and  is  constantly  accom- 
panied by  invagination  of  the  mesentery. 

Intussusception  may  occur  in  all  segments  of  the  large  and  small 
intestines,  but  with  very  varying  frequency.  In  general,  we  distin- 
guish invaginatio  enterica  (small  bowel  into  small  bowel),  invagi- 
natio  ileo-Gcecalis  (small  bowel  into  large  bowel),  and  invaginatio 
colica  (lai'ge  bowel  into  large  bowel).  Special  subdivisions  are  : 
itivaginatio  ileo-duodenalis,  dtiodeno-jejunalis,  jejunalis,  jejuno- 
iliaca,  ileo-colica,  iliaca-ileo-colica,  colica,  colica-rectalis,  and  rec- 


INTESTINAL  OBSTRUCTION 


385 


talis.  The  most  important  variety  is  invagination  of  the  small  into 
the  large  intestine  (see  Fig.  41),  which,  according  to  Leichtenstern, 
from  an  analysis  of  4Y9  cases,  occurs  in  52  per  cent  of  cases  at  all 
ages.  During  the  first  year  of  life  the  percentage  is  as  high  as 
YO  per  cent.     J^ext  in  frequency  are  iliac  (30  per  cent)  and  colic 


B.M. 


—Pr.v 


Ca— 4- 


—-li 


XL  Intussusception. 


/,  ileum  ;  /*,  invaginated  ileum ;  0,  cfecum ;  B.  M.,  mesenteric  base ;  Pr.v,  vermiform  appen- 
dix; Ca,  ascending  colon.    (Taken  from  the  collection  of  Prof.  Langerhans,  of  Berlin.) 

invaginations  (18  per  cent).  The  proportion  is  different  in  adults, 
for  the  iliac  and  ileo-caecal  varieties  are  of  about  equal  frequency. 
In  invagination  of  the  ileum  the  lower  portion  of  this  part  of  the 
bowel  is  usually  affected.  Colic  invaginations  are  more  frequent 
in  the  descending  colon  and  in  the  sigmoid  flexure  than  in  the 
other  portions  of  the  large  bowel. 


386  DISEASES   OP  THE  INTESTINES 

Invagination  occurs  most  frequently  in  cliildhood.  According  to 
Leichtenstern,  one  half  of  all  intussusceptions  occur  during  the  first 
decade.  In  the  first  year  of  Hf e,  and  particularly  between  the  fourth 
month  and  the  end  of  the  first  year,  invaginations  are  very  frequent. 

Regarding  sex,  the  majority  of  cases  occur  in  males.  The  chronio 
forms  are  found  most  often  between  the  twentieth  and  fortieth 
years  of  life  (50  per  cent) ;  then  follows  the  first  decade  with  a 
frequency  of  25  per  cent.  According  to  Raffinesque^^  in  51  cases 
of  chronic  invagination,  38  occurred  in  men  and  33  in  women. 

At  the  present  day  opinions  still  differ  regarding  the  etiology 
of  intussusception.  Contrasted  with  each  other  are  the  spasmodic 
(Dance,  Cruveilhier,  Beriton,  Bristowe,  Raffinesque,  Nothnagel)  and 
paralytic  theories,  the  latter  upheld  mainly  by  Leichtenstern.  Ac- 
cording to  the  former  theory  an  energetic,  circular  tetanic  contrac- 
tion of  an  isolated  portion  of  the  intestine  constitutes  the  starting 
point  of  the  inversion.  This  occurs  in  such  a  manner  "  that  the 
intestinal  segment  below  and  immediately  adjoining  the  spastically 
contracted  portion  is  drawn  up  over  the  latter"  (Nothnagel). 
Leichtenstern,  on  the  other  hand,  claims  that  the  bowel  segment 
in  question  becomes  paralyzed  through  certain  intercurrent  cir- 
cumstances (diarrhoea,  ingesta,  traumatism,  partial  peritonitis)  ;  this 
segment  is  then  everted  and  becomes  invaginated  with  the  enter- 
ing internal  contractile  bowel  lying  below.  The  latter  forms  the 
vaginal  portion  of  the  intussusception.  Again,  D'Arcy  Power ^^, 
who  has  won  renown  because  of  his  work  in  the  pathology  and 
operative  treatment  of  intussusception,  believes  that  a  disproportion 
between  the  width  of  the  ileum  and  caecum  is  the  true  cause.  If 
either  congenitally  or  otherwise  the  circumference  of  the  caecum 
is  considerably  increased,  a  predisposition  to  invagination  occurs. 
The  discussion  of  these  hypotheses,  which  are  thoroughly  described 
by  Nothnagel,  Leichtenstern,  and  Treves,  would  lead  us  too  far. 
Animal  experiments  and  theoretical  considerations  incline  me  to- 
ward the  spastic  theory. 

The  direct  causes  of  invagination,  according  to  the  statistics  of 
593  cases  gathered  by  Leichtenstern  ^^,  do  not  appear  to  be  uniform. 
In  111  apparently  healthy  individuals  the  disease  began  suddenly ; 
in  the  remaining  number  of  cases  the  following  etiological  factors 
were  found  :  intestinal  polypi  (30  cases),  intestinal  cancer  and  stric- 
ture (6  cases),  diarrhoea  (21  cases),  other  abnormal  intestinal  func- 
tions (25  cases),  ingesta  (28  cases),  abdominal  contusion  (14  cases), 
concussion   of    the    body   (12    cases),   invagination    during    preg- 


INTESTINAL   OBSTRUCTION  387 

nancy  or  puerperium  (Y  cases),  ''  catching  cold "  (6  cases),  various 
acute  and  chronic  diseases  as  well  as  indifferent  and  doubtful 
factors  (6Q  cases).  From  these  statistics  we  can  only  conclude 
that  we  are  absolutely  in  the  dark  regarding  the  real  causes  of 
intussusception. 

Symptomatology 

The  symptoms  of  intussusception  are  those  of  a  severe  intestinal 
obstruction  with  all  its  characteristics.  Because  of  their  peculiarity, 
the  pain,  vomiting,  character  of  evacuations,  the  condition  of  the 
abdomen,  and  the  tumour  formed  by  the  invaginated  bowel,  must 
be  described  in  detail. 

Spasmodic  pain,  the  first  and  most  prominent  symptom,  gen- 
erally appears  quite  suddenly — in  nurslings  while  at  the  breast,  in 
older  children  during  play,  in  adults  in  the  midst  of  work  or  per- 
haps at  night.  From  the  beginning  the  pain  is  usually  of  an 
extremely  threatening  character,  so  that  in  children  collapse  or 
convulsions  may  usher  in  the  disease,  while  in  adults  the  sever- 
ity of  the  pain  causes  the  patient  to  writhe  in  agony.  After 
the  initial  paroxysm — which  is  probably  caused  by  incarcera- 
tion of  the  mesentery — the  pain  may  become  continuous,  or, 
as  is  often  the  case,  may  cease  for  one  or  several  hours.  Dur- 
ing the  intermissions  the  patient  may  take  some  nourishment 
and  for  a  very  short  time  feel  comparatively  well.  The  pain 
may  cease  before  death  in  consequence  of  paralysis  of  the  pain 
centres,  but  there  are  many  cases  in  which  the  pain  continues 
till  death.  If  the  acute  invagination  becomes  chronic,  the  pain 
may  take  on  a  marked  paroxysmal  character,  just  as  has  been 
described  in  intestinal  stenosis.  The  site  of  the  pain  depends 
upon  the  part  of  the  bowel  affected,  and  varies  considerably. 
In  children  it  is  generally  limited  to  the  region  of  the  umbili- 
cus. In  adults  the  pain  may  be  localized  in  a  portion  of  the 
intestine  which  corresponds  fairly  well  with  the  seat  of  invagi- 
nation ;  this  fact  can  be  of  diagnostic  importance.  The  pain 
is  generally  accompanied  by  distressing  tenesmus.  The  character 
of  the  evacuations  (to  be  described  later)  and  the  tenesmus  may 
at  first  view  present  a  striking  similarity  to  that  of  acute  dysen- 
tery. The  tenesmus  is  much  more  severe  in  children  than  in 
adults,  so  that  paresis  of  the  sphincters  very  soon  results.  The 
higher  up  in  the  intestine  the  invagination  the  less  marked  is  the 
tenesmus,  and  vice  versa. 


388  DISEASES   OF   THE  INTESTINES 

In  cMldliood,  vomiting  accoin]3aiiies  tlie  pain  from  the  onset,  and 
maj  very  rapid  Ij  run  through  all  the  various  stages  (already 
described)  up  to  feculent  vomiting.  In  adults,  vomiting  is  by  no 
means  as  constant  as  in  the  other  forms  of  intestinal  obstruction. 
It  may  be  absent  throughout  or  may  occur  at  certain  intervals,  or, 
as  in  children,  it  may  be  very  violent  and  continuous.  These  vari- 
ous characteristics  depend  upon  the  greater  or  lesser  completeness 
of  the  obstruction,  upon  the  amount  of  the  mesentery  invaginated 
and  the  degree  of  its  compression,  and  upon  the  site  of  the  invagi- 
nation. Unfavourable  conditions  are  found  in  the  iliac,  ilio-csecal, 
and  ileo-colic  forms,  while  invaginations  of  the  large  bowel  gener- 
ally run  a  comparatively  mild  course.  As  in  intestinal  stenosis, 
vomiting  is  least  prominent  in  the  chronic  forms. 

The  character  of  the  evacuations  is  one  of  the  most  important 
objective  symptoms.  Invaginations  are  distinguished  from  most 
other  forms  of  intestinal  obstruction  in  that  evacuations  do  not 
immediately  cease,  but  one  or  more  stools,  evidently  deiived  from 
the  distal  intestinal  segment,  may  be  passed  after  the  onset  of  the 
intussusception.  If  real  stools  no  longer  occur,  there  may  be 
repeated  evacuations  of  blood,  blood  and  mucus,  blood  and  pus, 
or  of  gangrenous  masses.  In  these  cases  the  tenesmus  is  apt  to 
be  very  severe.  The  hemorrhages  constitute  one  of  the  most  con- 
stant symptoms;  they  are  absent  in  only  W  per  cent  of  acute  cases; 
they  vary  in  amount  according  to  the  site  and  extent  of  the 
invagination.  As  soon  as  the  process  becomes  subacute  the  hemor- 
rhages may  cease  or  temporarily  disappear.  On  the  other  hand, 
large,  gangrenous,  putrid  pieces  of  intestine  may  be  passed  per 
rectum.  In  chronic  invagination,  hemorrhage,  although  much  more 
frequent  than  in  other  forms  of  chronic  intestinal  stenosis,  may  be 
entirely,  or  almost  entirely,  absent.  Rarely  is  the  hemorrhage  large 
in  amount.  The  character  of  the  evacuations  varies  very  much  in 
chronic  invaginations,  and  scarcely  two  cases  are  alike. 

Aside  from  the  tumour  the  abdomen  presents  no  noteworthy 
changes.  Tympanites  is  rare  ;  when  present,  it  is  not  well  marked. 
It  is  least  when  diarrhoea  is  present,  somewhat  more  marked  with 
absolute  constipation,  and  extensive  only  when  peritonitis  super- 
venes. 

Formerly  the  presence  of  a  symptom  known  as  the  "  signe 
de  dance"  was  considered  important.  It  was  said  to  consist  in 
a  depression  in  the  right  inguinal  region  or  in  the  right  iliac  fossa, 
presumably  caused  by  displacement  of  the  caecum.     This  symptom 


INTESTINAL  OBSTRUCTION  389 

has  lost  all  value  after  Raffinesque^^  showed  that  even  in  chronic 
invaginations — those  most  favourable  for  this  sign — it  is  present  in 
only  about  4  per  cent  of  the  cases. 

The  invagination  tumour  is  of  much  greater  importance,  and  may 
even  be  pathognomonic.  It  may  be  palpated  through  the  abdo- 
men, or  through  the  rectum  or  vagina.  It  is  present  in  about  half 
of  all  acute  cases,  but  it  can  be  more  easily  found  and  palpated  in 
chronic  cases.  The  tumour  is,  however,  not  palpable  with  uniform 
frequency  in  all  varieties  of  invagination.  According  to  Treves,  it  is 
most  often  felt  in  intussusception  of  the  ileo-caecal  region  and  of  the 
caecum,  least  so  in  that  of  the  small  intestines  and  in  the  ileo-colic 
form.  The  tumour  is  more  clearly  demonstrable  in  children  than 
in  adults.  This  is  due  to  the  fact  that  in  the  former,  because  of 
the  softer  abdominal  walls,  tumours  can  be  more  easily  felt.  As 
Henoch  ^  states,  even  in  such  favourable  cases  the  tumour  may  be 
obscured  by  distended  coils  of  intestine.  The  tumour  may  vary  in 
size  from  a  hen's  eg^g  to  that  of  the  adult  forearm.  It  is  smooth, 
moderately  hard,  of  varying  consistency,  sausage-shaped,  and  some- 
what curved.  The  smaller  tumours  are  the  more  frequent.  The 
size  of  the  tumour  that  can  be  mapped  out  by  palpation  does  not 
always  correspond  to  its  real  extent,  for  portions  may  be  obscured 
at  the  flexures  of  the  colon.  The  tumour  is  found  most  frequently 
over  the  ascending,  next  over  the  transverse  colon.  When  lying  in 
the  caecal  region  it  indicates  an  ileal  invagination.  The  invagi- 
nation tumour,  like  all  other  intestinal  tumours,  is  characterized 
by  relatively  great  mobility.  It  is  therefore  very  difficult,  from  the 
position  of  the  invagination  tumour,  to  correctly  diagnosticate  the 
original  seat  and  kind  of  invagination.  Provided  it  is  not  fixed 
by  adhesions,  the  tumour  can  be  moved  from  without,  sometimes 
even  to  a  very  marked  degree.  It  may  temporarily  disappear,  and 
therefore  Treves's  warning,  never  to  diagnosticate  the  absence  of 
a  tumour  unless  the  abdomen  is  examined  during  a  paroxysm  of 
pain,  is  timely.  Examination  at  the  height  of  an  attack  of  colic 
offers  the  best  opportunity  for  distinctly  palpating  the  tumour,  and, 
at  the  same  time,  determining  the  existence  of  tetanic  intestinal 
rigidity.  The  latter  is  rarely  found  in  acute  invagination ;  in 
chronic  forms  it  is  quite  readily  demonstrable. 

In  acute  as  well  as  in  chronic  cases  there  may  be  prolapse  of  the 

invagination  tumour  through  the  rectum.     It  generally  occurs  in 

acute  invagination,  and  is  most  frequent  in  the  ileo-csecal  and  colic 

forms.     When  prolapsed,  it  may  be  directly  palpated,  and  is  seen  as 

26 


390  DISEASES  OF  THE  INTESTINES 

a  hypergemic  or  partly  gangrenous  tumour.  Its  origin  is  evident 
by  the  appearance  at  one  point  of  the  ileo-csecal  opening,  and  next 
to  it  a  second  opening,  that  of  tlie  appendix.  Simple  as  is  the 
demonstration  of  a  prolapsed  invagination  tumour  numerous  errors 
have  been  made.  For  instance,  invagination  tumours  have  been 
mistaken  for  prolapse  of  the  rectum,  for  polypi,  or  for  hemori'hoids, 
and  have  been  excised.  Treves  reported  several  remarkable  in- 
stances in  which,  despite  these  operative  errors,  cures  resulted. 
The  reverse  has  also  occurred,  viz.,  that  other  tumours  (a  false 
diverticulum,  at  another  time  a  blood  coagulum)  have  been  mis- 
taken for  an  invagination  tumour.  Such  confusion  can  generally 
be  avoided  by  careful  and  repeated  examination,  particularly  under 
narcosis. 

Diagnosis 

Of  all  forms  of  intestinal  obstruction,  acute  intussusception  offers 
the  most  favourable  opportuAities  for  early  diagnosis. 

Among  the  suhjective  symptoms  we  must  consider  the  sudden 
onset  in  the  midst  of  good  health,  the  immediate  occurrence  of 
intense  pain  of  a  convulsive  or  intermittent  character,  and  the 
vomiting  (by  no  means  so  violent  as  in  other  forms  of  obstruction, 
and  feculent  in  only  about  25  per  cent  of  all  cases).  Tenesmus, 
present  in  about  50  per  cent  of  all  cases,  is  of  special  diagnostic 
significance.  As,  of  all  varieties  of  obstruction,  it  is  found  in 
volvulus  of  the  sigmoid  flexure  alone,  and  here  relatively  seldom,  I 
believe  that  well-defined,  tenesmus  is  one  of  the  most  positive  sub- 
jective symptoms  of  invagination.  Disturbances  of  general  health 
vary  so  much  according  to  the  age  of  the  patient,  the  site,  the  special 
type,  and  the  condition  of  the  invagination,  that  they  need  scarcely 
to  be  considered  in  a  diagnostic  connection. 

The  most  important  of  the  objective  signs  is  the  presence  of  a 
tumour.  As  already  mentioned,  a  tumour  is  demonstrable  only  in 
about  one  half  of  the  cases.  In  obscure  forms  we  would  strongly 
recommend  repeated  examinations,  particularly  during  a  paroxysm 
of  pain.  At  this  time  the  invagination  tumour  approaches  the  ante- 
rior abdominal  wall.  By  careful  consideration  of  the  remaining 
symptoms  the  character  of  the  tumour  will  scarcely  ever  remain 
unrecognised. 

If  the  tumour  projects  from  the  rectum,  its  peculiarities  will 
immediately  point  to  the  diagnosis.  The  character  of  the  evacua- 
tions is  also  a  significant  and  possibly  diagnostic  phenomenon.    Ab- 


INTESTINAL  OBSTRUCTION  391 

solute  constipation  is  generally  absent.  In  addition,  there  is  the 
frequency  of  bloody  evacuations,  or  evacuations  consisting  of  blood 
and  mucus,  or  of  pus  mixed  with  gangrenous  shreds.  As  already 
mentioned,  bloody  evacuations  also  occur  in  incarceration  and 
strangulation,  but  the  passing  of  purulent,  gangrenous  masses  is 
typical  of  acute  intussusception.  "When  we  suspect  intussuscep- 
tion, early  examinations  of  the  stools  and  search  for  small  micro- 
scopical amounts  of  pus  should  be  made ;  such  examinations  may 
clear  up  an  otherwise  obscure  clinical  picture.  For  further  diag- 
nostic data  see  chapter  on  Differential  Diagnosis. 

The  diagnosis  of  chronic  intussusception  is  often  quite  difficult. 
Raffinesque^^  mentions  that  in  55  cases  collected  by  him  the  diag- 
nosis was  incorrect  in  no  less  than  2T.  Here,  again,  pain  is  the 
most  important  and  occasionally  the  most  valuable  subjective  symp- 
tom. It  is  so  often  markedly  intermittent  (coliclike)  in  character 
that  it  may  indeed  be  taken  as  the  type  of  colic  pain.  Accompany- 
ing the  pain,  intestinal  rigidity  with  all  the  characteristics  of  the 
tetanic  contractions  of  intestinal  stenosis  (see  page  356)  generally 
occurs.     The  patients  themselves  are  conscious  of  this  rigidity. 

Vomiting  is  not  a  reliable  diagnostic  symptom  of  chronic  invagi- 
nation. Its  frequency  and  degree  vary  considerably.  The  stools 
present  nothing  characteristic.  As  Treves  *  remarks,  "  the  only  cer- 
tain feature  in  the  state  of  the  bowels  in  chronic  invagination  is 
the  feature  of  uncertainty."  Of  importance  in  this  connection  is 
the  experience  of  Eaffinesque^^,  that  diarhoea  is  present  in  about 
one  half  of  all  chronic  cases.  I  have  found  no  reports  in  medical 
literature  concerning  the  presence  of  pus  in  the  evacuations ;  such 
a  condition  is  without  doubt  more  rare  than  it  is  in  the  acute  form. 

Of  the  objective  symptoms  the  most  important  is  the  invagina- 
tion tumour.  When  well  marked  it  is  of  greater  diagnostic  value 
than  any  other  symptom,  Regarding  the  nature  of  the  tumour, 
we  refer  the  reader  to  the  section  on  symptomatology.  In  chronic 
intussusception  the  invaginated  bowel  not  infrequently  extends  to 
the  rectum  (according  to  Raffinesque  in  about  one  third  of  the  cases) 
and  may  be  felt  there.  This  is  rare  in  the  beginning,  but  more 
frequent  in  the  later  stages  of  the  disease.  Just  as  in  acute  cases, 
meteorism  is  not  well  marked,  and  the  course  of  the  affection  and 
general  condition  of  the  patient  present  no  special  diagnostic  char- 
acteristics. 

*  Loe.  cit.,  p.  100  [English  edition,  p.  420]. 


392  DISEASES  OF   THE  INTESTINES 

IV.    Bending,  Kinking,  Adhesions,  Mesenteric 
Contractions,  Compression 

In  previous  sections  we  have  described  those  forms  of  obstruc- 
tion caused  by  clefts,  fenestra,  false  bands,  etc.,  which  may  pro- 
duce severe  incarceration  or  strangulation.  There  is,  however, 
another  group,  more  infrequent  and  clinically  less  severe,  in  which 
intestinal  obstruction  may  be  produced  by  isolated  peritoneal  adhe- 
sions. They  are  distinguished  from  the  above  group  in  that  both 
small  and  large  intestine  are  affected  with  equal  frequency.  The 
same  is  true  of  compression  of  the  bowel  from  without  by  other 
conditions  (e.  g.,  new  growths). 

Treves,*  who  has  carefully  described  these  forms  of  obstruction, 
distinguishes  the  following  varieties : 

1.   Obstruction  over  a  Band 

"If  several  coils  of  a  thin  India-rubber  pipe,  through  which 
water  was  flowing,  were  thrown  over  a  tightly-drawn  wire,  the 
lumen  of  the  tube  would  become  more  or  less  completely  occluded 
at  the  spot  where  the  wire  was  crossed  "  (Treves). 

Yery  similarly  we  may  imagine  that  if  one  or  more  coils  of 
intestine  are  drawn  across  a  taut  tissue  strand,  the  intestinal  lumen 
will  be  narrowed.  Through  irregular  peristalsis  and  partial  adhe- 
sion of  the  coil  to  the  band  more  favourable  conditions  for  such  an 
occurrence  are  created.     Treves  discovered  only  4:  of  these  cases. 

2.  Obstruction  from  Acute  Kinking  Due  to  Traction  upon  an 

Isolated  Band  or  an  Adherent  Diverticulum 

In  this  instance  a  band  attached  to  the  bowel  so  drags  upon  its 
point  of  attachment  that  the  intestine  is  acutely  bent  at  the  latter 
point,  and  is  finally  completely  occluded.  This  condition  is  most 
frequently  met  with  in  Meckel's  diverticulum  or  in  isolated  bands 
connected  with  the  ileum.  The  ileum,  because  of  its  short  mesen- 
tery, is  particularly  predisposed  to  kinking.  Owing  to  its  tendency 
to  displacements,  the  large  intestine  may  also  become  kinked  or  bent. 

3.  Obstruction  from  Adhesions    which   retain    the   Bowel  in   a 

Bent  Position 

The  site  of  these  abnormal  bands  is  either  the  abdominal  or  the 
pelvic  wall  or  the  abdominal  organs,   as  the  liver,  kidneys,  and 

*  Loc.  cit.,  p.  100,  etc.  [English  edition  (1899),  p.  75,  etc.]. 


INTESTINAL  OBSTRUCTION  393 

spleen.  The  etiological  factors  are  traumatism,  pelvic  peritonitis, 
perityphlitis,  incarcerated  and  reduced  hernise,  etc.  The  kinking 
may  be  single  or  multiple — a  fact  to  be  remembered  at  laparotomies. 
The  kinking  may  give  no  symptoms  during  life,  may  partially 
obstruct  the  passage  of  the  fseces,  or,  in  consequence  of  some  exter- 
nal or  internal  influence,  may  suddenly  cause  all  the  symptoms  of 
an  acute  intestinal  obstruction.  The  forms  of  intestinal  obstruc- 
tion so  frequently  observed  after  reduction  of  femoral  hernise  are 
striking  examples  of  this  variety. 

4.  Obstruction  hy  Means  of  Adhesions  of  Intestinal  Coils  to  Each 

Other 

This  may  occur  both  in  the  small  and  large  intestines.  In  the 
former  it  is  most  frequent  with  hernise.  If,  for  example,  a  large  coil 
is  markedly  compressed  in  the  neck  of  the  hernial  canal,  adhesions 
develop  at  this  point ;  after  reduction  of  the  hernia  these  remain. 
Only  the  portions  of  the  loop  that  were  compressed  become  adher- 
ent (open  loop).  In  small  incarcerated  hernise,  on  the  contrary, 
the  entire  loop  of  the  bowel  in  question  is  bound  together  by  adhe- 
sions (closed  loop).  Similar  adhesive  bands  occur  after  intestinal 
ulceration  with  consecutive  local  peritonitis,  or,  as  Treves  specially 
points  out,  as  the  result  of  cheesy  degeneration  of  mesenteric  glands. 

Adhesions  between  coils  of  the  large  bowel  occur  particu- 
larl}^  after  displacements  or  ulcers  of  this  portion  of  the  intestine. 
Displacements  have  been  discussed  in  detail  in  a  previous  chapter 
(see  page  255).  From  these  changes  in  position  accumulations  of 
faeces  occur  and  catarrhal  changes  easily  develop ;  stercoral  ulcers 
may  result,  and  cause  local  peritonitis  and  adhesions  to  the  adjoin- 
ing part  of  the  bowel  or  other  abdominal  organs. 

In  recent  years  Kelling^^  and  Westphalen^^  have  shown  that 
adhesions  between  the  transverse  colon  and  the  liver  occur  and 
cause  a  number  of  intestinal  disturbances  (pain  accompanying 
peristalsis). 

5.  Obstruction  due  to   Traction   ttpon   the   Intestinal  Wall  by  a 

Diverticulum 

Treves  has  called  attention  to  a  stricture  which  is  characterized 
by  marked  narrowing  of  the  small  intestine  and  by  numerous  ulcera- 
tions of  the  mucous  membrane  above  the  stricture.  Complete  intes- 
tinal obstruction  may  here  result  from  distortion  of  the  bowel  wall 
by  a  diverticulum. 


394:  DISEASES  OF  THE  INTESTINES 

6.  Narrowing  of  the  Bovjel  from  shrinking  of  the  Mesentery  after 

Inflammation 

The  affection  first  described  by  Yircbow  under  the  name  of 
peritonitis  chronica  mesenterialis  apparently  plays  a  much  greater 
part  in  the  etiology  of  intestinal  obstruction  than  was  formerly  sup- 
posed. In  one  year,  for  example,  Riedel^'''  observed  no  less  than 
8  cases  resulting  from  such  cicatrization.  The  usual  site  of  mesen- 
teric inflammation  with  subsequent  cicatricial  contraction  is  the 
sigmoid  flexure,  where,  as  already  stated,  it  may  lead  to  volvulus. 
This  process  also  occurs  at  the  ceecum,  and,  as  Riedel  has  recently 
shown,  in  the  mesentery  of  the  small  intestine  as  well  as  in  the 
peritoneum  of  the  posterior  abdominal  wall.  Besides  volvulus  of 
the  sigmoid,  mesenteric  contraction  causes  a  displacement  through 
traction  of  some  part  of  the  intestines  and  disturbances  of  intesti- 
nal mobility ;  such  disturbances  may  present  the  picture  of  chronic 
bowel  stenosis,  or  in  extremely  severe  cases  they  may  lead  to  acute 
intestinal  obstruction, 

7.   Comjpression  of  the  Bowel  from  Without 

This  term,  in  its  narrowest  sense,  means  the  pressure  produced 
in  an  intestinal  segment  by  a  body  adjoining  it;  such  pressure 
either  narrows  or  completely  obliterates  the  intestinal  lumen.  Com- 
pression is  generally  caused  by  malignant  or  benign  neoplasms, 
which  may  belong  to  the  most  varied  organs  (stomach,  intestines, 
liver,  pancreas,  spleen,  kidney,  lymph  glands,  mesentery,  pelvic 
bones,  uterus,  ovaries,  etc.).  A  tumour  originating  in  the  intestines 
may  compress  a  neighbouring  segment. 

Besides  neoplasms,  other  pathological  conditions  may  compress 
the  bowel  from  without ;  for  example,  a  retroflexed  uterus,  large  vesi- 
cal calculus,  peri-  and  paratyphlitic  abscesses,  floating  spleen  and 
floating  kidney,  tumours  of  the  pancreas  from  hemorrhage  or 
cysts,  etc. 

Owing  to  its  situation,  the  rectum  is  most  often  pressed  upon, 
usually  by  pelvic  tumours.  According  to  Leichtenstern,  this  occurs 
in  60  per  cent  of  all  cases.  Then  follow  in  order  of  frequency  the 
sigmoid  flexure,  descending  colon,  the  lower  portion  of  the  ileum, 
duodenum,  and,  finally,  the  ascending  colon  and  hepatic  flexure, 
middle  portion  of  the  ileum,  and  transverse  colon. 

In  this  connection  it  is  important  to  remember  the  peculiar 
compression  of  the  small  intestines  (duodenum  or  ileum)  recently 


INTESTINAL  OBSTRUCTION  395 

described  by  Schnitzler  ^^.  It  is  produced  by  the  mesentery  of  coils 
of  the  small  intestine  which  have  descended  into  the  pelvic  cavity. 
In  a  similar  manner,  from  traction  of  the  pylorus  in  consequence  of 
extreme  gastrectasia  and  by  compression  of  the  duodenum  and  other 
portions  of  small  intestine,  the  clinical  picture  of  acute  incarceration 
may  be  produced  (L.  Meyer  ^^). 

Symptomatology  and  Diagnosis 

The  clinical  symptoms  of  the  above  forms  of  intestinal  occlu- 
sion possess,  on  the  one  hand,  the  character  of  stenosis,  and,  on 
the  other,  that  of  obstruction,  and  both  conditions  may  suddenly 
or  slowly  interchange  with  the  other.  The  few  differential  diag- 
nostic signs  described  in  the  literature  of  the  subject  are  not  suffi- 
cient to  distinguish  these  forms  from  other  similar  ones.  We 
shall  therefore  not  give  any  detailed  account  of  them.  Aside 
from  several  marked  instances  (obstruction  after  hernial  reduc- 
tion), one  fact  deserves  mention — the  course  of  the  disease  is  gen- 
erally milder  and  slower  than  the  forms  previously  described. 

Under  certain  conditions  the  diagnosis  of  these  affections  may 
be  made,  i.  e.,  where  the  cause  of  the  occlusion  is  visible  or  pal- 
pable (e.  g.,  tumours,  palpable  adhesions),  or  where  the  history 
points  directly  to  the  nature  of  the  disease  (obstruction  following 
hernial  reduction,  local  peritonitis  following  traumatism,  appendi- 
citis with  adhesions,  previous  operations,  etc.).  The  fact  that  these 
forms  of  obstruction  affect  adults  rather  than  children,  and  also 
that,  as  above  stated,  the  symptoms  are  generally  less  severe  than 
in  strangulation,  incarceration,  or  volvulus,  may  sometimes  possess 
diagnostic  importance.  The  exceptions  are  so  numerous,  however, 
that  in  a  given  case  the  last-mentioned  data  must  be  cautiously 
taken  into  account. 

V.  Internal  Intestinal   Stricture 

Internal  strictures  are  produced  by  ulcerations  with  consequent 
cicatricial  contractions,  by  cancerous  strictures,  and  by  inflammatory 
(hypertrophic)  conditions  of  the  intestinal  wall. 

The  ulcerations  to  be  considered  are  the  tubercular,  stercoral, 
dysenteric,  typhoid,  and  syphilitic.  Tubercular  ulcers  are  among 
the  most  frequent  causes  of  intestinal  stricture ;  the  other  forms 
have  little  practical  importance.  As  is  well  known,  syphilitic 
ulceration  is  most  frequent  in  the  lowest  portions  of  the  bowel, 
especially  in  the  rectum,  and  is  extremely  rare  in  the  upper  por- 


396  DISEASES   OF   THE  INTESTINES 

tions  of  tlie  intestine.  Strictures  due  to  previous  ulcerative  pro- 
cesses also  occur  in  incarcerated  hernia  and  after  traumatism. 
Finally,  tlie  peculiar  strictures  accompanying  pernicious  anaemia, 
to  which  Knud  Faber  ^°  has  recently  called  attention,  must  be  men- 
tioned. 

Cancerous  ulcerations  are  mainly  found  in  the  large  bowel  and 
rectum ;  they  are  characterized  by  a  tendency  to  the  formation  of 
stricture.  Since  ulcerations,  neoplasms,  and  their  sequelse  have 
already  been  discussed  in  a  separate  section,  a  detailed  account  of 
these  affections  will  not  again  be  necessary. 

Symptomatology  akd  Diagnosis 

As  regards  the  intestinal  stricture  or  obstruction,  the  symp- 
tomatology is  the  same  as  that  described  in  the  previous  section. 
Special  symptoms,  when  present,  are  evidenced  by  the  special 
form  of  the  underlying  disease  (tumour,  syphilis,  tuberculosis,  dys- 
entery, etc.). 

This  is  true  also  of  the  diagnosis.  Where  constitutional  changes 
or  a  characteristic  tumour  point  directly  to  the  cause  of  the  affec- 
tion, the  correct  diagnosis  can  be  made ;  in  other  cases  it  may 
only  be  possible  to  say  that  there  exists  a  stricture  or  total  occlu- 
sion, or  perhaps  to  determine  approximately  the  portion  of  the 
bowel  affected. 

In  stricture  of  the  small  intestine  we  should,  on  account  of  its 
frequency,  first  suspect  tuberculosis  as  the  probable  cause.  In 
stricture  of  the  large  intestine,  exclusive  of  the  csecum,  we  must 
think  of  cancer.  Syphilitic  stenoses  and  stenoses  due  to  sclerotic 
changes  in  the  submucosa  can  not,  in  the  present  state  of  our  knowl- 
edge, be  positively  diagnosticated. 

VI.  Obstruction   from    Foreign    Bodies 

In  this  category  are  included  gallstones,  intestinal  concretions, 
instruments  introduced  per  os  or  per  anum,  and  inspissated  faeces. 

{a)  Obstruction  hy  Gallstones 

This  may  occur  in  all  parts  of  the  intestinal  canal  from  the 
pylorus  to  the  rectum,  but  the  different  segments  are  not  affected 
with  equal  frequency.  Those  most  frequently  involved  are  the 
lower  portion  of  the  ileum  and  the  ileo-caecal  valve — i.  e.,  the 
divisions  which,  for  anatomical  reasons  (narrow  lumen  of  the  lower 


INTESTINAL  OBSTRUCTION  397 

ileum,  short  taut  mesentery),  offer  most  resistance  to  tlie  passage 
of  large  stones;  next  in  frequency  are  tlie  duodenum  and  jeju- 
num. Obstruction  by  gallstones  is  rarer  in  the  upper  or  mid- 
dle portions  of  the  ileum,  and  is  extremely  rare  in  the  colon  and 
rectum.  In  the  vast  majority  of  cases  the  stone  passes  into  the 
intestine  through  a  fistula  which  has  resulted  from  inflammatory 
adhesions  between  the  gall  bladder  and  the  intestines.  Commu- 
nication between  gall  bladder  and  duodenum  is  the  most  fre- 
quent occurrence,  while  that  between  small  intestine  and  colon  is 
rarer.  Stones  have  been  known  to  enter  the  duodenum  thi-ough 
a  choledocho  -  duodenal  fistula.  Gallstones  may  cause  intestinal 
obstruction  in  other  ways.  Thus,  Mikulicz^  twice  found  gall- 
stones, not  in  the  intestinal  canal,  but  in  diverticuli  of  the  cystic 
duct  which  lay  across  and  compressed  the  duodenum.  The  obser- 
vations of  J.  Israel^  and  Körte ^^  have  shown  that  smaller  stones 
may  produce  intestinal  obstruction,  probably  by  exciting  circular 
spastic  contraction  of  the  bowel.  When  a  stone  has  been  impacted 
for  a  long  time,  and  is  large  and  angular,  it  may  produce  inflamma- 
tion and  swelling  of  the  intestinal  wall,  or  even  gangrene  and  peri- 
tonitis with  or  without  perforation. 

Symptomatology 

It  is  well  known  that  obstruction  by  gallstones  is  met  with 
more  frequently  in  women  than  in  men.  Regarding  age, 
l^anuyn^"*  has  found  among  120  cases  only  5  under  the  age  of 
thirty,  and  only  7  between  thirty-one  and  forty  years  of  age, 
while  there  were  96  cases  between  the  ages  of  forty-one  and 
sixty.  After  the  latter  period  there  is  again  a  decided  decrease 
in  frequency. 

In  many  cases  (according  to  Lobstein^^  17  times  in  90)  there 
is  a  previous  history  of  attacks  of  biliary  colic,  or  more  rarely 
of  jaundice.  It  is  important  to  inquire  whether  the  patient  has 
suffered  from  paroxysmal  attacks  of  so-called  "  stomach  ache," 
which,  as  a  rule,  are  nothing  more  than  ill-defined  attacks  of  chole- 
lithiasis. 

In  other  cases  the  history  may  point  to  a  local  peritonitis  as  the 
cause  of  the  rupture  into  the  intestines,  or  only  a  doubtful  connec- 
tion can  be  established. 

The  symptoms  of  intestinal  obstruction  vary  widely  according 
to  the  location  of  the  stone.  As  already  mentioned  (page  3^6),  the 
stone,  when  situated  high  up  in  the  duodenum,  produces  symptoms 


398  DISEASES   OP  THE   INTESTINES 

of  pyloric  stenosis ;  in  tlie  descending  portion  of  the  duodenum  con- 
tinued bilious  vomiting  is  one  of  the  characteristic  symptoms ;  still 
farther  down,  the  usual  symptoms  of  obstruction  of  the  small  intes- 
tines occur — reflex  vomiting,  which  may  very  soon  become  fecu- 
lent or  even  faecal,  visible  or  palpable  intestinal  peristalsis,  more  or 
less  (generally  less)  meteorism,  and  finally  retention  of  stool  and 
gases.  I^^aunyn  ^'',  the  greatest  authority  on  cholelithiasis,  observes 
that  in  intestinal  obstruction  by  gallstones  the  retention  of  stool  and 
flatus  is  not  necessarily  absolute.  Collapse  soon  follows ;  it  is  sel- 
dom of  the  severe  type  met  with  in  other  forms  of  intestinal  obstruc- 
tion. In  unfavourable  cases  death  occurs  between  the  fifth  and  tenth 
days  of  the  disease,  rarely  later.  There  may  be  a  favourable  ter- 
mination if  the  stone  has  been  forced  through  the  narrowest  part 
of  the  gut — that  is,  if  the  stone  has  passed  into  the  large  intes- 
tine;  here,  however,  it  may  remain  for  days  before  it  is  passed 
per  anum.  On  the  other  hand,  a  cure  does  not  result  in  all  cases 
in  which  the  stone  has  been  passed.  An  intestinal  lesion  may 
remain  which  may  later  produce  death  from  perforative  peritonitis. 
'Not  rarely,  as  ISTaunyn^'  states,  the  lumen  of  the  bowel  may  only 
temporarily  remain  pervious,  and  after,  days,  or  even  weeks,  again 
become  obstructed.  Finally,  two  attacks  of  obstruction  by  gall- 
stones have  been  observed  in  the  same  individual.  Eeports  show 
that  if  there  be  a  fistulous  communication  between  the  gall  blad- 
der and  colon,  large  stones  may  pass  without  causing  symptoms  of 
obstruction. 

Diagnosis 

In  diagnosticating  obstruction  from  gallstones  it  is  necessary  to 
determine  that  there  really  is  a  calculous  obstruction,  and,  if  pos- 
sible, the  site  of  the  stone.  In  favourable  cases  (i.  e.,  where  the 
obstruction  is  situated  high  up)  when  evidences  of  former  chole- 
lithiasis or  of  a  communication  of  the  gall  passages  with  the  upper 
intestinal  tract  are  present,  it  is  possible  to  estabhsh  both  the  above 
facts.  If  the  history  is  not  reliable,  and  if  objective  signs  of  pre- 
vious cholelithiasis  (enlargement  of  the  liver,  painful  gall  blad- 
der, and  pressure  sensitiveness  of  the  posterior  portion  of  the  Hver) 
are  absent,  a  probable  diagnosis  may  be  made  by  exclusion.  We 
must  remember  that  incarceration,  strangulation,  volvulus,  perito- 
neal adhesions,  and  internal  stricture  of  the  upper  part  of  the  in- 
testinal canal  (duodenum,  jejunum)  are  relatively  rare.  Mistakes 
cannot,  however,  be  avoided.     If  the  stone  is  impacted  lower  down 


INTESTINAL  OBSTRUCTION  399 

in  the  bowel,  the  diagnosis  may  be  easy  when  a  well-defined  history 
is  obtained,  or  when  characteristic  changes  about  the  liver  or  gall 
bladder  are  found.  In  all  cases  of  intestinal  obstruction,  there- 
fore, one  should  carefully  examine  and  palpate  the  liver  and  gall 
bladder. 

Yery  rarely  a  tumour  is  palpable  on  the  left  or  right  side 
of  the  abdominal  cavity  (Kirmisson-Rochard  ^^,  Sick^,  Köstlein^^, 
Dessauer  ^^).  Maclagan  ^'^  has  observed  two  cases  in  which  a  pain- 
ful tumour  T/as  felt  in  the  neighbourhood  of  the  liver,  and  when 
this  tumour  disappeared  symptoms  of  intestinal  obstruction  gradu- 
ally developed.  If  none  of  the  above-mentioned  data  can  be 
obtained  the  differential  diagnosis  from  other  forms  of  intestinal 
obstruction  will  be  difficult.  When  there  is  a  suspicion  of  obstruc- 
tion from  gallstones  repeated  rectal  and  vaginal  examinations  should 
be  made,  for  gallstones  have  thus  been  demonstrated  in  the  intes- 
tines. Gallstones  in  the  rectum  may  be  digitally  or  instrumen- 
tally  removed. 

Visible  intestinal  peristalsis  may  make  possible  the  localization 
of  the  obstruction,  but  it  can  seldom  be  observed,  and  is  also  found 
in  other  forms  of  intestinal  obstruction. 

As  previously  mentioned,  the  large  intestine  is  rarely  occluded 
by  gallstones  (1  case  of  Körte  ^^  and  2  cases  of  Courvoisier  ®^). 
This  may,  however,  occur  in  the  rectum,  when  the  peculiar  symp- 
toms (tenesmus,  obstinate  constipation,  pain)  will  direct  immediate 
attention  to  the  site  of  the  trouble. 

{b)  Obstruction  by  Enteroliths 

We  have  already  described  the  different  varieties  of  intestinal 
concretions  (page  112).  They  generally  originate  in  the  large 
intestine,  for  in  this  situation  conditions  are  most  favourable  for 
the  development  of  hard  concretions.  They  are  chiefiy  situated  in 
the  haustra  coli  or  in  the  rectal  ampulla.  In  the  small  intestine 
concretions  due  to  stagnation  of  the  contents  may  develojj  in  the 
so-called  true  or  false  diverticula  They  occur  most  often  in  young 
persons,  and  particularly  in  the  poorer  classes  who  subsist  mainly 
on  vegetables,  rather  than  in  the  better  classes,  whose  diet  contains 
more  animal  matter.  Intestinal  concretions  form  very  gradually. 
"  They  may,  moreover,  be  dormant,  as  it  were,  for  years,  or  excite 
during  that  time  but  insignificant  symptoms  "  (Treves).* 

*  Log.  cit.,  S.  336  [and  Intestinal  Obstructions,  page  199]. 


400  DISEASES  OP  THE  INTESTINES 

S  TMPTOMATOLOGT 

The  symptoms  of  this  variety  of  obstruction  resemble  those  of 
chronic  stenosis,  viz.,  constipation,  attacks  of  vomiting,  paroxysms  of 
pain,  and  disturoances  of  general  health.  In  a  few  cases  large  con- 
cretions have  been  felt  through  the  abdominal  walls  or  through  the 
rectum.  Occasionally  fragments  have  been  passed  with  the  stools. 
By  reason  of  its  powerful  muscular  coat  and  its  elasticity,  the  large 
intestine  permits  of  the  passage  of  very  large  concretions ;  hence 
severe  symptoms  of  obstruction  have  very  rarely  been  observed 
(case  of  Down  ^^).  Where  the  concretion  is  retained  in  the  caecum 
it  may  produce  all  the  symptoms  and  sequel se  of  typhlitis  or  peri- 
typhlitis. 

Diagnosis 

A  positive  diagnosis  of  an  intestinal  concretion  can  only  be 
made  when  the  concretion  can  be  felt  per  rectum.  The  diagno- 
sis is  perhaps  most  likely  to  be  made  when  a  tumour  is  palpable, 
when  symptoms  of  partial  obstruction  are  present,  when  the  gen- 
eral condition  of  the  patient  and  the  very  protracted  course  of 
tlie  affection  speak  against  carcinoma,  and  when  the  customary 
food  of  the  patient  has  been  such  as  to  favour  the  formation  of 
concretions. 

(c)  Obstruction  from  Entozoa  {Ileus  Yerminosus) 

Opinion  is  still  divided  as  to  whether  entozoa  (chiefly  ascarides) 
may  cause  intestinal  obstruction.  Leichtenstern  ^,  Davaine™,  and 
Heller''^  doubt  its  occurrence,  while  Mosler  and  Peiper"^^  answer 
the  question  in  the  affirmative.  In  his  Bibliographie  d.  klinischen 
Helminthologie,  Huber  cites  13  cases  of  obstruction  caused  by  a 
large  accumulation  of  ascarides  in  the  intestines.  It  occurs  almost 
exclusively  in  children.  The  ileo-csecal  valve  is  said  to  be  the  main 
site  of  the  occlusion.  Whether  the  obstruction  is  of  a  mechanical 
nature,  or  whether,  as  seems  more  probable,  it  is  dynamic  (reflex) 
in  character,  is  as  yet  undecided.  In  the  vast  majority  of  cases  the 
disease  runs  an  unfavourable  course.  Held  en  reich ''^  has  reported  a 
successful  case  of  enterostomy  and  Simon '''^  one  of  colostomy  for 
this  condition.  Yery  few  of  the  observations  heretofore  made  will 
stand  critical  examination  ;  it  is  therefore  impossible  to  describe  the 
characteristic  symptoms.  The  diagnosis  is  only  possible  through 
the  accidental  evacuation  of  ascarides,  which  is  usually  a  result  of 
therapeutic  measures. 


INTESTINAL  OBSTRUCTION  401 

{d)  OhstruGtion  hy  Foreign  Bodies  which  have  heen  Introduced 

Foreign  bodies  that  have  been  purposely  or  accidentally  intro- 
duced may  reach  the  intestines  through  the  mouth  or  anus.  Most 
remarkable  bodies  have  thus  found  their  way  into  the  intestinal 
canal.  ISTeurotic  patients  have  swallowed  very  dangerous  arti- 
cles, frequently  with  suicidal  intent,  but  occasionally  also  when 
mentally  deranged.  Both  old  and  recent  literature  is  replete  with 
such  instances,  which  are  simply  medical  curiosities  and  hence 
need  only  be  mentioned.  We  refer,  however,  to  the  recent  thor- 
ough article  of  Frikker'^^,  who  describes  a  unique  case  which  oc- 
curred in  his  own  practice.  Coins  and  similar  articles,  or  false 
teeth,  are  most  frequently  swallowed. 

Symptomatology 

If  their  size  or  length  is  not  disproportionate  to  the  lumen  of 
the  intestinal  canal,  swallowed  articles  generally  pass  through  the 
bowels  without  trouble.  This  is  also  true  of  pointed  or  sharp 
bodies  (nails,  files,  needles).  In  the  majority  of  instances  their 
expulsion  is  painless,  and  cause  no  symptoms  of  any  kind. 

If  the  foreign  body  is  not  passed,  it  is  apt  to  be  retained  in 
certain  portions  of  the  alimentary  canal  —  the  stomach,  lower 
segment  of  the  ileum,  duodenum,  and  more  especially  the  caecum 
and  ampulla  recti.  Even  then  symptoms  are  not  necessarily  pres- 
ent; they  may  appear  only  after  the  expiration  of  months  or 
years.  There  may  be  pain,  colic,  vomiting,  more  or  less  complete 
constipation,  ulceration  of  the  mucous  membrane  with  perforative 
or  local  peritonitis,  or  with  resultant  stricture  or  abscess  opening 
externally.  After  having  passed  through  the  intestinal  wall,  nee- 
dles may  be  carried  to  different  parts  of  the  body,  and  extrude 
spontaneously  or  be  artificially  removed. 

Diagnosis 

The  diagnosis  of  swallowed  foreign  bodies  can  be  made  either 
from  the  history  or  from  direct  evidence.  Eegarding  bodies  intro- 
duced into  the  rectum  direct  evidence  should  by  all  means  be 
obtained.  In  all  other  intestinal  segments  such  evidence  is  only 
exceptionally  obtainable  by  palpation.  Metallic  foreign  bodies  are 
best  demonstrated  and  located  by  radiography. 

My  experience  has  shown  that  patients  often  imagine  they  have 
swallowed  articles  (needles,  false  teeth,  etc.).     I  once  "  removed  " 


402  DISBASES  OF   THE   INTESTINES 

a  needle — presumably  swallowed — from  a  hysterical  female  by  show- 
ing;' her  a  needle  in  the  water  of  an  enema. 

{e)  Obstruction  from  Fcecal  Tumours 

In  marked  habitual  constipation  accumulations  of  fsecal  matter 
may  obstruct  the  lumen  of  the  bowel.  These  tumours  occur  only 
in  the  large  intestine,  and  particularly  where  the  faeces  are  apt 
to  be  retarded — i,  e.,  in  the  csecum,  at  the  flexures,  and  especially 
the  sigmoid  flexure.  The  longer  the  fsecal  mass  is  retained,  the 
greater  is  its  loss  in  water  and  its  chances  for  increase  in  size  from 
further  fgecal  accumulation.  ISTotwithstanding,  these  masses  only 
exceptionally  produce  total  obstruction,  for  there  is  always  suffi- 
cient space  for  fluids  and  semisolid  fseces  to  pass  between  the 
tumour  and  the  intestinal  wall. 

Obstruction  of  the  kind  just  described  may  produce  other  and 
occasionally  serious  consequences.  The  frequent  development  of 
sigmoid  volvulus  from  impaction  has  already  been  mentioned. 
Furthermore,  as  described  in  the  section  on  Cancer  of  the  Large 
Intestine,  a  fsecal  mass  may  be  impacted  in  front  of  a  stenosis  in 
such  a  manner  as  to  directly  cause  intestinal  obstruction.  As  a 
result  of  stagnation  of  faeces,  there  may  be  a  descent  of  intestinal 
coils,  especially  of  the  movable  transverse  colon,  with  consequent 
kinking  or  the  formation  of  stercoral  ulcers,  and,  in  extreme  cases, 
as  a  result  of  exhaustion  of  the  muscular  coat  of  the  bowels,  there 
may  be  complete  arrest  of  the  faeces.     (See  Ileus  Paralyticus.) 

Symptoms 

These  are  mainly  those  of  chronic  partial  or  complete  intes- 
tinal obstruction.  Some  differences  arise  from  the  varying  situa- 
tions of  the  fsecal  tumour.  Thus,  when  situated  low  down  (sigmoid 
flexure,  rectum)  there  is  tenesmus ;  when  higher  up  the  latter  is 
absent.  The  most  important  symptom  is  the  fsecal  tumour  itself, 
whose  special  peculiarities  have  been  discussed  in  the  General 
Division. 

Diagnosis 

It  is  usually  easy  to  recognise  fsecal  tumours  in  the  lower  por- 
tion of  the  large  intestine  by  abdominal,  rectal,  or  vaginal  palpa- 
tion. If  the  mass  is  situated  in  the  upper  portion  of  the  large 
bowel,  the  diagnosis  is  more  difiicult,  particularly  when  meteorism 
obscures  the  tumour.     In  such  cases  the  history  and  clinical  course 


INTESTINAL  OBSTRUCTION  403 

alone,  more  especially,  however,  repeated  observations  of  similar 
more  or  less  severe  attacks,  may  lead  to  the  correct  diagnosis. 
Even  here,  however,  there  must  always  be  a  lurking  suspicion  of 
some  organic  hindrance,  of  incomplete  or  beginning  volvulus,  peri- 
toneal adhesions,  kinkings,  or  compressions.  It  is  still  more  diffi- 
cult to  decide  whether  the  palpable  fsecal  tumour  is  the  cause  or 
result  of  the  occlusion.  Only  complete,  permanent  relief  from  all 
the  symptoms  warrants  a  good  prognosis. 

VII.  Obstruction  without  Physical  Changes  in  the  Intestines 
(Paralytic,  Spastic,  and  Dynamic  Obstructions) 

Besides  intestinal  obstruction  from  mechanical  hindrance,  there 
is  a  second  form  in  which  the  symptoms  of  obstruction  are  pres- 
ent without  any  discoverable  cause.  The  older  practitioners  rec- 
ognised this  seemingly  paradoxical  condition.  In  1865,  Henrot, 
in  a  thesis  classical  even  at  the  ]3resent  time,  gave  an  exhaustive 
description  of  these  pseudo-etranglernents. 

The  conditions  are  most  readily  understood  when  the  intes- 
tines have  been  injured  in  some  manner — e.  g.,  by  severe  trauma- 
tism or  continued  constipation  or  abnormally  great  meteorism.  At 
present  we  are  unable  to  explain  the  origin  of  a  sudden  severe 
intestinal  paresis.  It  may  be  theoretically  explained,  however, 
that  there  are  marked  changes  in  the  innervating  fibres  of  the 
muscular  coat  of  the  bowels,  and  that  these  changes  cause  the 
paresis.  In  other  cases  the  paralysis  is  evidently  due  to  reflex 
action  (the  paralysie  reflexe  of  the  French).  A  classic  instance  is 
that  of  the  undescended  testicle,  which,  when  inflamed,  may  cause 
symptoms  of  intestinal  obstruction ;  or,  as  recently  demonstrated 
by  numerous  examples,  an  operation  has  been  performed  on  the 
intestines,  uterus,  or  ovaries,  and  there  develops  severe  intes- 
tinal obstruction  without  any  discoverable  lesion  in  the  intestinal 
wall  itself.  Whether  the  dynamic  intestinal  obstruction  often 
found  in  peritonitis,  and  particularly  in  perityphlitis,  is  reflex,  or 
whether,  as  Stokes  maintained,  it  is  caused  by  a  serous  infiltra- 
tion of  the  bowel  wall  (collateral  oedema),  in  which  case  modern 
writers  would  claim  toxins  as  etiological  factors,  or  finally,  whether 
it  is  produced  by  lessened  absorption  (and  hence  accumulation) 
of  gases,  is  a  question  which  cannot  at  present  be  answered  with 
certainty. 

Based  upon  several  observations,  Leichtenstern  ^^  has  proposed 
another  theory  to  explain  the   intestinal   paralysis   of   peritonitis. 


404  DISEASES   OP   THE  INTESTINES 

According  to  tliis  author,  when  the  patient  is  lying  on  his  back 
those  distended  intestinal  coils  which  have  long  mesenteries  are 
lifted  lip  by  the  gases  in  them  and  pressed  toward  the  ante- 
rior abdominal  wall,  while  coils  with  fluid  contents,  particularly 
those  with  short  mesenteries,  cannot  move  or  can  move  but  little 
from  the  vertebral  column.  Because  of  their  weight,  the  stagnant 
fluid  contents  of  the  duodenum  or  jejunum  are  much  more  likely 
to  flow  back  into  the  stomach  than  they  are  to  pass  into  the  dis- 
tended, paralytic  bowel,  which  lies  higher  up  and  is  held  in  place 
by  the  meteorism.  This  explanation,  however,  is  suflicient  only 
for  isolated  cases,  since  the  above  condition  is  absent  in  many  cases 
of  peritonitis  with  marked  tympanitis. 

Sjjastic  obstruction  {ileus  spasmodica)  is  a  second  form  of 
dynamic  ileus,  and  one  whose  importance  has  only  lately  been 
acknowledged. 

In  spastic  ileus  there  develops  in  any  portion  of  the  intes- 
tines a  "  spastic  obstruction  "  which  may  be  followed  by  the  same 
changes  as  a  mechanical  obstruction.  Heidenhain '''^,  by  his  vivisec- 
tion experiments,  has  again  brought  this  subject  into  prominence. 
Spastic  obstruction  occurs  under  the  most  widely  different  condi- 
tions :  as  primary  spastic  obstruction  without  discoverable  cause, 
as  a  complication  of  hysteria  (very  remarkable  instances  have  re- 
cently been  described  by  von  Leube '"  and  Strauss),  in  gallstone 
obstruction  without  mechanical  intestinal  occlusion  (J.  Israel^, 
Körte  ^^),  as  a  reflex  condition  in  mechanical  ileus  (Heidenhain), 
in  crises  gastriques  (Sandoz'''^),  in  tubercular  intestinal  ulcerations 
(Strehl"*^),  and  with  foreign  bodies  in  the  rectum  which  do  not 
entirely  close  its  lumen  (Grundzach  ^).  The  case  described  by 
the  last-mentioned  author  appears  to  me  to  be  an  especially  good 
example  of  sjjastic  intestinal  obstruction ;  I  shall  therefore  briefly 
describe  it : 

After  eating  a  hearty  supper  a  man,  thirty  years  of  age,  complained  of  ab- 
dominal pain,  tenesmus,  constipation,  absence  of  flatus,  and  anorexia.  Castor 
oil  and  calomel  were  given  without  result.  Stomach  and  intestines  markedly 
distended :  abdomen  sensitive  to  pressure ;  face  anxious.  Beginning  intestinal 
obstruction  was  suspected.  Rectal  examination  discovered  a  fishbone,  5  to  6 
centimetres  long,  lying  crosswise  in  the  rectum.  After  extraction  of  the  bone 
the  patient  very  soon  passed  flatus  and  fluid  stools. 

Leichtenstern  ^  is  of  the  opinion  that  the  intestinal  spasm  is 
simply  a  persistence  of  the  muscle  in  a  condition  of  elastic  tension. 


INTESTINAL  OBSTRUCTION  405 

IN^othnagel  -  also  considers  this  possible.  There  are  cases  (for  exam- 
ple, the  one  just  described,  and  that  of  gallstone  obstruction  with- 
out occlusion)  which  point  more  conclusively  to  a  spasmodic  con- 
dition than  to  one  due  to  intestinal  paralysis.  From  a  practical 
standpoint,  however,  both  conditions  are  the  same. 

Symptomatology 

The  clinical  picture  of  functional  intestinal  obstruction  is  so 
very  similar  to  that  of  the  various  forms  of  mechanical  obstruction 
already  described,  that  we  should  only  have  to  repeat  what  has 
been  said.  From  this  it  will  be  seen  that  a  demonstrable  and  ob- 
jective differentiation  between  these  two  general  forms  is  very  diffi- 
cult. It  might  be  stated  that  visible  peristalsis  is  absent  in  func- 
tional occlusion,  but  then  it  is  also  quite  often  absent  in  mechanical 
ileus. 

Diagnosis 

Under  the  above  circumstances  the  diagnosis  is  extremely  diffi- 
cult. This  is  appreciable  when,  for  example,  we  have  to  differen- 
tiate between  peritonitis  with  intestinal  paralysis  and  mechanical 
obstruction.  In  the  introductory  part  of  this  chapter  (page  368) 
we  have  described  the  factors  that  have  to  be  considered.  When 
there  are  symptoms  of  obstruction  after  operations  upon  the  intes- 
tines or  the  sexual  organs,  or  after  reduction  of  a  hernia,  the  con- 
ditions may  be  so  favourable  that  a  correct  diagnosis  is  possible. 
Everybody  who  is  acquainted  with  the  literature  of  this  subject 
knows  that  diagnostic  errors  are  very  apt  to  be  made,  for  it  will 
scarcely  be  possible  to  exclude  apparently  insignificant  mechanical 
causes  (slight  adhesions,  circumscribed  peritonitis,  intestinal  com- 
pression, and  crushing).  For  these  reasons  many  surgeons  are 
sceptical  regarding  dynamic  obstruction. 

Differential  Diagnosis  between  the  Seveeal  Forms  of 
Intestinal  Obstruction 

In  the  majority  of  cases  it  is  impossible  to  make  a  correct  diag- 
nosis of  the  variety  and  localization  of  the  obstruction.  In  prac- 
tice we  must  often  be  contented  when  we  have  approximately 
determined  the  site  of  the  lesion  and  the  probable  cause  of  the 
occlusion. 

The  first  question  to  be  determined  is  whether  the  obstruction 

*  Loc.  cit.,  S.  360. 
27 


406  DISEASES  OF  THE  INTESTINES 

is  in  the  large  or  the  small  intestine.  In  what  follows,  therefore, 
we  shall  briefly  describe  the  symptoms  which  indicate  the  localiza- 
tion of  the  obstruction  in  one  or  the  other  parts  of  the  intestinal 
tract. 

{a)  Small  Intestine. — Here  objective  signs  to  a  slight  degree, 
but  more  especially  the  knowledge  gained  from  experience,  aid  in 
making  the  diagnosis.  Experience  may  be  of  great  service.  "We 
herewith  give  an  example :  Sudden  intestinal  obstruction  occurs  in 
a  young  man  who  has  always  been  well.  ]^o  hernia;  very  rapid, 
extremely  acute  development,  with  vomiting  soon  becoming  fsecal ; 
no  flatus  or  stool  passed ;  intense  indicanuria  from  the  very  onset 
of  the  disease  ;  no  marked  meteorism.  In  such  a  case  we  may, 
without  fear  of  error,  diagnosticate  obstruction  of  the  small  bowel. 
A  second  example  is  the  following :  An  elderly  woman,  well  except 
for  obstinate  habitual  constipation,  is  attacked  with  symptoms  of 
slight  obstruction.  No  stool  or  flatus  passed,  slight  vomiting,  not 
faecal  in  character;  marked  localized  meteorism;  marked  tenesmus. 
Here  we  need  have  no  great  hesitation  in  diagnosticating  an  obstruc- 
tion of  the  large  bowel,  probably  a  sigmoid  volvulus. 

No  doubt  there  are  cases  in  which  from  the  very  onset  the  symp- 
toms are  so  obscure  that  the  diagnosis  of  the  site  of  the  lesion  is 
only  a  matter  of  personal  experience,  or  rather  of  personal  equation. 
Regarding  such  doubtful  cases,  it  must  be  mentioned  that  occlusions 
of  the  large  bowel  generally  present  better  objective  signs  than  those 
of  the  small  bowel.  Rectal  injections  or  inflation,  recognition  of  a 
large,  fixed,  distended  intestinal  coil  by  means  of  auscultatory  percus- 
sion, the  possibility  of  palpating  this  intestinal  coil,  the  previously 
described  lumbar  symptoms  of  Nothnagel  (page  355) ;  the  recogni- 
tion of  mild  peristalsis — all  these  combined  will  in  favourable  cases 
lead  to  comparatively  certain  conclusions.  It  has  often  been  men- 
tioned that  examinations  per  rectum  and  vagina,  and  of  the  evacua- 
tions, may  yield  important,  and,  under  certain  circumstances,  deci- 
sive results.  Error  is  unavoidable  in  those  apparently  rare  cases 
of  simultaneous  obstruction  of  both  large  and  small  intestines,  de- 
scribed by  Treves  in  his  monograph,  and  lately,  after  several  opera- 
tions, by  Hochenegg^^  (combination  ileus).  Furthermore,  as  already 
mentioned,  the  occurrence  of  multiple  invaginations,  cicatricial  stric- 
tures, peritoneal  adhesions,  volvuli,  etc.,  should  be  remembered.  Such 
conditions  cannot  be  recos-nised  during  life. 

After  the  local  diagnosis  has  been  made  other  difiiculties  must  be 
overcome.     We  can,  however,  often  reach  a  diagnosis  by  exclusion. 


INTESTINAL  OBSTRUCTION  40Y 

The  differential  diagnosis  of  the  nature  of  the  obstruction  must 
necessarily  be  limited  to  those  conditions  which  are  at  all  capable 
of  being  diagnosticated.  Hence  we  must  exclude  constriction  by 
omental  bands,  incarcerations  by  the  appendix  or  by  Meckel's  diver- 
ticulum, by  pseudo-membranes,  fenestra  or  clefts  in  the  mesen- 
tery, or  by  adhesions  of  several  intestinal  coils ;  occlusion  by  kink- 
ing or  distortion,  by  the  formation  of  knots,  volvuli  (excepting  sig- 
moid volvulus) ;  internal  hernise  (with  the  possible  exception  of 
diaphragmatic  hernia).  We  do  not  wish  to  imply  that  the  diag- 
nosis of  these  forms  of  obstruction  can  never  be  made,  but  that 
they  can  be  recognised  only  under  particularly  favourable  and 
rather  accidental  circumstances. 

Deplorable  as  this  is,  it  enables  us  to  restore  order  out  of  this 
diagnostic  chaos,  by  allowing  ns  to  study  more  carefully  the  few 
recognisable  and  distinguishable  varieties  of  obstruction.  For  this 
purpose  a  detailed  history,  a  careful  study  of  the  patient's  condi- 
tion, and  an  accurate  knowledge  of  the  symptomatology  of  intes- 
tinal obstruction  are  necessary. 

As  Gräser ^^  states,  the  history  and  the  patient's  daily  condition 
should  always  be  noted  in  writing,  and  any  changes  should  be 
compared  with  previous  observations.  If  careful  observation  at 
home  is  not  possible,  doubtful  cases  should  immediately  be  sent  to 
a  suitable  hospital. 

I^aunyn  rightly  observes  that  in  all  forms  of  intestinal  obstruc- 
tion the  first  practical  question  is  whether  or  not  an  incarceration 
or  a  strangulation  is  present.  In  not  a  few  instances  this  ques- 
tion may  be  answered  affirmatively  because  of  the  severe  initial 
symptoms — violent  shock,  almost  constant  intestinal  jDain,  early 
vomiting  soon  becoming  faecal,  and  collapse  very  rapidly  reaching 
the  greatest  possible  severity.  The  important  objective  symptoms 
of  incarceration  and  strangulation  are  the  distended,  fixed  intes- 
tinal coil  (occasionally  with  peristalsis),  hemorrhagic  exudate  into 
the  dependent  portion  of  the  abdomen,  meteorism,  moderate  or 
absent,  large  intestinal  hemorrhages  (rare)  (Kaunyn),  and  marked 
indicanuria  from  the  beginning  of  the  disease.  The  first  symp- 
tom (von  Wahl's)  is  the  most  important,  but  unfortunately  it  is 
not  always  well  marked.  As  previously  mentioned,  it  is  entirely 
absent  when  the  strangulation  aifects  a  large  part  of  the  intestine. 
In  such  cases  it  is  impossible  to  diagnosticate  more  than  the  site 
of  obstruction.  JN'othnagel's  case  (mentioned  on  page  382)  shows 
that  there  are  exceptions  even  to  these  rules. 


408  DISBASES  OF  THE  INTESTINES 

Among  the  forms  of  obstruction  of  the  small  intestine  that  can 
be  diagnosticated  we  must  consider  obstruction  by  gallstones.  The 
facts  that  are  of  value  for  the  diagnosis  of  doubtful  cases — and  these 
alone  are  here  considered — are  the  age  of  the  patient  (generally  over 
thirty- one  years),  sex  (more  frequent  in  the  female),  the  history 
(which  may,  however,  leave  us  entirely  in  the  dark),  some  change 
(though  but  slightly  indicated)  in  the  liver,  especially  the  pro- 
tracted course,  the  passing  of  flatus,  and,  despite  fsecal  vomiting,  of 
stool,  and,  finally,  the  shght  tympanites.  Hemorrhages  per  anum 
do  not  speak  against  gallstone  obstruction.  When  the  obstruction 
is  situated  high  up— i.  e.,  in  the  vicinity  of  the  papilla— the  picture 
is  in  itself  very  characteristic,  although  the  cause  of  the  occlusion 
may  remain  obscure  if  the  history  does  not  contain  data  which 
call  attention  to  the  possibility  of  intestinal  obstruction  by  a  gall- 
stone. The  case  might,  however,  be  one  of  obstruction  due  to 
compression  by  neighbouring  tumours  (which  need  not  necessarily 
be  palpable),  by  adhesions  with  surrounding  tissues  (gall  bladder, 
pylorus,  mesentery,  etc.),  by  ulcers  with  cicatrization  (Yarr),  and 
by  torsion  of  the  mesentery  (J.  Schuitzler). 

Foreign  hodies  impacted  in  the  small  bowel  can  be  diagnosti- 
cated only  Avhen  there  is  a  history  of  their  having  been  introduced  ; 
otherwise  this  is  not  distinguishable  from  other  forms  of  obstruc- 
tion, especially  that  by  gallstones. 

(b)  As  already  mentioned,  obstructions  of  the  large  intestine  are 
more  readily  recognised  and  their  nature  determined  than  are  ob- 
structions of  the  small  intestine.  There  is  less  danger  of  an  error 
in  intussusception  than  in  any  other  form.  Its  occurrence  in  very 
young  children,  its  sudden  onset,  the  severe  but  generally  intermit- 
tent pain,  the  tenesmus,  the  characteristic  discharges  (especially  the 
admixture  of  23us  and  blood),  the  presence  of  a  smooth,  growing,  and 
wandering  tumour  which  occasionally  becomes  tetanically  contracted 
and  is  sometimes  directly  palpable  and  visible  per  rectum,  in  some 
cases  the  passing  of  a  sloughing,  gangrenous  intussusception — all 
these  symptoms,  taken  together  or  separately,  are  so  characteristic 
that  doubt  as  to  the  correct  diagnosis  can  occur  only  under  partic- 
ularly unfavourable  circumstances.  In  the  differential  diagnosis  we 
must  consider  rectal  polypi  with  bloody  stools  (which  are,  however, 
easily  distinguished  from  invaginations),  acute  dysentery,  and  severe 
intestinal  colic.  In  the  early  stage  of  the  disease  it  is  sometimes 
impossible  to  distinguish  the  latter  condition  from  intussusception, 
but  the  diagnosis  is  almost  always  cleared  up  by  the  further  course 


INTESTINAL  OBSTRUCTION  409 

of  tlie  affection.  On  the  other  hand,  it  is  usually  impossible 
to  correctly  diagnosticate  an  invagination  accompanied  by  a  neo- 
plasm. 

Generally,  volvulus  of  the  sigmoid,  the  second  most  frequent 
form  of  obstruction  of  the  large  bowel,  also  presents  a  character- 
istic picture.  Its  main  diagnostic  features  are  the  occurrence  late 
in  life  and  in  persons  suffering  from  obstinate  constipation,  the 
sudden  development  combined  with  a  relatively  slow  course,  ab- 
sence of  faecal  vomiting  despite  complete  intestinal  obstruction, 
futility  of  rectal  injections  of  large  quantities  of  water '^  (less 
than  one  half  litre),  marked  meteorism,  which  may  extend  over 
the  whole  abdomen  or  may  become  quite  visible  and  be  limited 
to  a  fixed  coil,  but  without  peristalsis,  frequent  tenesmus,  and 
finally  slight  indicanuria.  Bloody  evacuations  occur  in  volvulus 
of  the  sigmoid  flexure  as  well  as  of  the  small  intestine,  in  in- 
vaginations, and  but  rarely  in  obstructions  from  gallstones.  The 
other  symptoms  vary  so  widely  that  only  rarely  ought  there  to  be 
any  difficulty  in  differentiating  between  these  conditions.  We 
may,  however,  have  to  determme  whether  we  are  dealing  with  a 
simple  volvulus,  or  with  a  volvulus  produced  by  a  carcinomatous 
stricture  or  a  tumour.  When  a  tumour  is  absent,  it  will  generally 
be  impossible  to  make  the  differentiation.  In  itself  the  clinical 
picture  is  not  sufficiently  characteristic  to  enable  us  to  state  whether 
we  are  dealing  with  a  complete  volvulus  of  360  degrees  or  with 
one  of  180  degrees. 

Occlusions  of  the  large  intestine  which  develop  in  the  later 
stages  of  a  stricture  (generally  carcinomatous  or  tubercular)  are  also 
easily  recognisable.  If  a  tumour  is  present,  there  can  only  be  doubt 
as  to  its  nature ;  frequently  the  further  course  of  the  disease  will 
clear  up  the  case  (compare  chapter  on  Intestinal  Neoplasms).  If 
there  is  no  tumour,  we  can  arrive  at  more  than  a  probable  diag- 
nosis only  in  the  presence  of  other  definite  clinical  data — tuber- 
cular symptoms,  pyrexia,  age,  metastases,  caneer  cachexia,  etc. 
Usually  it  is  impossible  to  determine  whether  the  obstruction  is 
caused  by  paralysis  of  the  intestinal  wall,  or  by  foreign  bodies  or 
fgeces  impacted  in  front  of  the  stenosis,  or  by  other  mechanical 
factors. 

Foreign  hodies  in  the  large  intestine  which  have  been  swallowed 
can  be  diagnosticated  from  the  history ;  others  can  only  be  recog- 

*  Compare,  however,  limitations,  given  on  page  382. 


410  DISEASES  OF  THE  INTESTINES 

nised  when  found  in  the  rectum,  or  when  fragments  of  them  are 
accidentally  passed  per  rectum.  Of  importance,  too,  is  the  fact  that 
enteroliths  are  generally  found  in  the  csecum,  and  produce  symp- 
toms of  typhlitis  or  intestinal  stenosis  before  the  symptoms  of 
obstruction  appear.  Occasionally  a  tumour  may  be  felt  in  the 
caecum,  but  its  nature  will  be  doubtful.  On  the  whole,  however, 
enteroliths  will  seldom  have  to  be  considered  in  the  differential 
diagnosis. 

As  mentioned  in  the  general  division  (p.  76),  fmcal  tumours  of 
the  large  bowel  have  often  given  rise  to  error.  One  who  has  had 
any  experience  with  these  pseudo-tumours  will,  I  believe,  scarcely 
ever  be  misled.  Even  when  these  tumours  consist  of  old  residua, 
their  compressibility  and  elasticity  will  usually  indicate  the  proper 
diagnosis.  Difficulty  will  only  arise  when,  in  addition  to  the  fsecal 
tumour,  a  real  neoplasm  is  present,  or  when  the  clinical  course 
points  to  a  neoplasm.  The  case  taken  from  Kothnagel's  Diseases 
of  the  Intestines,  and  cited  on  page  77,  is  a  very  good  example  of 
this.  For  the  diagnosis  of  a  fsecal  tumour,  the  clinical  course  is 
very  important,  and  the  history  may  give  us  valuable  information. 
Faecal  tumours  produce  symptoms  of  occlusion  very  gradually,  and 
these,  when  present,  are  relatively  mild.  The  general  health  is  but 
little  affected ;  there  is  absence  of  fsecal  vomiting,  of  a  fixed  dis- 
tended intestinal  coil  (a  point  of  differentiation  from  volvulus  of  the 
large  intestine),  and  of  visible  peristalsis.  This  latter  condition  is 
always  present  in  stricture  of  the  large  bowel. 

(c)  Dynmnio  Intestinal  Ohsl/puction. — If  we  obtain  a  history  or 
other  evidence  of  laparotomies  or  operations  on  the  female  genitals, 
of  traumatism,  reduced  hernise,  the  diagnosis  of  functional  (dynamic) 
obstruction  ought  not  to  be  very  difficult ;  but  even  in  these  cases 
a  positive  differentiation  is  sometimes  not  easy.  For  example,  in 
obstruction  following  hernial  reduction  it  is  hard  to  state  whether 
the  obstruction  is  of  a  mechanical  (incomplete  reduction,  adhesions 
of  incarcerated  intestinal  coils)  or  of  a  functional  nature ;  or,  when 
a  volvulus  has  been  untwisted,  it  is  difficult  to  state  whether  the 
intestine  has  not  been  twisted  anew,  or  whether  the  volvulus  was 
the  only  obstructing  factor;  or  whether  we  are  not  dealing  with 
an  obstruction  of  a  dynamic  type.  As  will  be  seen  when  we  shall 
come  to  speak  of  the  treatment,  these  questions  are  not  purely  hypo- 
thetical. It  is  important  for  the  physician  to  know  them  before  he 
begins  treatment.  The  differential  diagnosis  can  be  made  only  by 
a  study  of  each  separate  case  and  by  the  most  careful  consideration 


INTESTINAL  OBSTRUCTION  411 

of  all  details.  "When  applied  to  a  complicated  case,  every  tabulated 
scheme  utterly  fails. 

We  have  already  mentioned  that  in  these  cases  we  must  also 
think  of  hysteria,  for  the  latter  condition  may  cause  much  diagnos- 
tic difficulty. 

Since  it  has  been  thoroughly  discussed  (p.  368,  etc.),  we  shall 
not  enter  into  the  diiferentiation  between  mechanical  and  dynamic 
ileus  and  acute  peritonitis. 

It  is  evident  that  the  varieties  of  obstruction  which  permit  of  a 
positive  diagnosis  are  not  numerous,  and  even  this  small  group 
presents  new  phases  and  abnormalities  which  may  absolutely  dis- 
guise the  typical  clinical  ensemble. 

The  Tkeatment  of  Strictures  and  Obstructions  of  the 

Intestine 

Although  physicians  differ  in  many  points  regarding  the  treat- 
ment of  these  affections,  all  agree  that  we  are  concerned  with  one 
of  the  most  difficult  and  responsible  fields  of  internal  pathology. 
This  is  owing,  no  doubt,  to  the  uncertainty  which  attends  all  cases 
which  can  be  recognised  clinically,  but  more  especially  those  far 
more  numerous  cases  in  which  the  diagnosis  is  obscure.  Even  in 
so  simple  a  condition  as  internal  stenosis  of  the  large  bowel  we  can- 
not be  certain  of  the  degree  of  obstruction  or  the  condition  of  the  mus- 
cular layers  of  the  gut  above  the  seat  of  obstruction.  We  can  note  the 
efforts  of  the  hypertrophied  intestinal  segment  to  force  f gecal  matter 
through  the  stricture,  but  who  can  say  whether  it  will  finally  succeed, 
and,  if  so,  when  ?  What  is  the  anatomical  condition  of  the  stricture  ? 
How  far  has  it  advanced  peripherally  ?  Is  rupture  impending  ?  It 
is  almost  impossible  to  answer  any  of  these  questions.  This  is  also 
true  of  intestinal  occlusions.  Let  us  take  the  simplest  example, 
that  of  volvulus  of  the  sigmoid  flexure.  Is  the  volvulus  complete, 
or  incomplete  ?  Is  it  primary,  or  caused  by  a  cicatricial  stricture 
of  benign  or  malignant  character  ?  What  is  the  condition  of  the 
twisted  bowel  ?  Is  there  danger  of  peritonitis  ?  Is  it  beginning, 
or  has  it  already  begun  ?  These  questions  are  of  the  greatest  impor- 
tance both  as  regards  the  treatment  to  be  instituted  and  the  life  of 
the  patient ;  still  it  is  impossible  to  clearly  and  precisely  answer 
any  of  them.  If,  then,  typical  cases  are  so  perplexing,  how  much 
greater  the  difficulty  in  cases  which  do  not  even  admit  of  localiza- 
tion, let  alone  of  an  anatomical  diagnosis. 

The  difficulty  in  the  selection  of  a  method  of  treatment  is  due 


412  DISEASES  OF  THE  INTESTINES 

not  so  much  to  the  doubtfulness  of  the  gross  diagnosis,  as  to  the 
fact  that  we  know  so  Httle  of  the  condition  of  the  occhided  seg- 
ment during  any  stage  of  the  disease.  Other  considerations  influ- 
ence our  action  in  individual  cases — viz.,  the  age  of  the  patient,  his- 
tory of  previous  exhausting  disease,  general  condition,  comphcating 
constitutional  dyscrasise,  etc.  Owing  to  these  difficulties,  it  is  im- 
possible to  give  a  schematic  account  of  the  treatment  of  intestinal 
obstruction.  The  efforts  of  both  surgeons  and  medical  men  in  dif- 
ferent countries  have  hitherto  been  unsatisfactory,  because  they 
have  had  no  common  facts  on  which  to  base  their  plans  of  treat- 
ment. Only  a  most  comprehensive  collective  study,  such  as  has 
been  so  well  carried  on  by  Sahli  in  perityphlitis,  may  clear  up  the 
disputed  points.  At  present  we  must  be  content  to  give  an  account 
of  what  can  be  gathered  from  the  rich  surgical  and  medical  litera- 
ture of  the  subject,  and  from  my  own  experience  concerning  the 
different  methods  of  treatment, 

I.   Treatment  of  Intestinal  Strictures 

Unless  we  are  dealing  with  a  foreign  body  which  may  be  passed 
per  mas  naturales^  it  is  impossible  to  cure  an  intestinal  stricture  by 
internal  medication.  The  medical  practitioner  can  only  assist  in  the 
efforts  already  begun  by  nature  to  compensate  for  the  obstruction. 
We  possess  several  means  to  attain  this  end  :  appropriate  diet  and 
mechanical  and  medical  remedies. 

{a)  Diet. — In  the  General  Division  we  have  described  the  appro- 
priate nourishment  in  intestinal  stenosis.  In  the  section  on  Intes- 
tinal Carcinoma  (page  323)  there  are  special  comments  which  may 
be  directly  applied  to  the  other  forms  of  chronic  stricture  of  the 
bowel. 

While  referring  the  reader  to  the  above  sections,  we  shall  here 
briefly  recapitulate  the  most  important  facts.  The  caloric  value 
of  the  diet  must  be  as  great  as  possible.  The  lower  the  site  of 
the  stricture  the  less  will  be  the  difficulty  of  carrying  out  these 
principles.  The  higher  the  occlusion,  the  greater  will  be  the 
accumulation  of  undigested  material.  The  condition  is  similar  to 
that  in  gastrectasia ;  the  same  difficulties  are  encountered  in 
stenoses  of  the  small  bowel  situated  high  up  as  in  dilatation  of 
the  stomach. 

We  must  again  call  attention  to  the  necessity  of  avoiding 
food  indigestible  or  difficult  of  digestion,  especially  if  it  contain 
much  cellulose. 


INTESTINAL  OBSTRUCTION  413 

In  stenosis  of  the  small  intestine  the  food  should  be  fluid  or 
semifluid,  and  should  contain  appropriate  physiological  laxatives. 
We  need  not  regard  the  general  warning  against  so-called  flatu- 
lent food,  which  exists  only  in  the  imaginations  of  thoughtless  peo- 
ple ;  we  should  outline  the  diet  according  to  the  individual  case. 
The  practitioner  who  distributes  printed  diet  sheets  shows  that  he 
has  no  conception  of  the  importance  of  diet  in  modern  therapy. 
In  far  advanced  stenosis  of  the  small  intestine  nutrient  enemata 
may  be  required.  For  the  details  or  technic  of  this  procedure  the 
reader  is  referred  to  other  works  on  this  subject.* 

{h)  Mechanical  Treatment. — This  consists  in  the  use  of  stomach 
lavage  and  rectal  enemata.  The  former  is  used  only  in  stenoses  of 
the  small  intestine.  Since  its  technic  is  quite  similar  to  that  em- 
ployed in  dilatation  of  the  stomach,  we  refer  the  reader  to  text- 
books on  diseases  of  that  organ.  Rectal  enemata  may  be  employed 
in  stenosis  of  both  the  large  and  the  small  intestines  when,  as  fre- 
quently happens,  laxatives  must  be  avoided.  They  may  be  of  great 
value  in  stenosis  of  the  small  intestine,  and  in  high  stenoses  of 
the  large  intestine  (occasionally  in  connection  with  mild  laxatives). 
Thorough  irrigation  of  the  rectum  is  most  appropriate,  or  else  small 
enemata  of  oil  or  soap,  with  glycerin,  oil,  cod  liver  oil,  etc.,  may  be 
given.     (Regarding  particulars,  see  Chapter  XI.) 

(c)  Medical  Treatment. — The  first  question  to  be  considered  is 
the  treatment  by  laxatives.  They  are  indispensable  in  the  therapy 
of  intestinal  stenosis,  for,  with  but  few  exceptions,  the  patients  suf- 
fer from  constipation  or  from  alternating  constipation  and  diarrhoea. 
We  have  discussed  this  subject  in  the  General  Division  (page  189), 
but  must  again  emphasize  that  drastic  purges  are  always  contra- 
indicated. 

Ojpium  and  its  alkaloids,  as  well  as  the  belladonna  preparations, 
are  used  in  intestinal  stenosis  either  as  sedatives  or  (and  this  can- 
not be  too  strongly  emphasized)  as  laxatives.  This  is  especially 
true  where  there  is  visible  and  palpable  intestinal  spasm.  Thus,  in 
a  case  of  stenosing  cancer  of  the  csecum  which  I  had  observed  for  a 
long  time,  and  in  which  symptoms  of  acute  occlusion  were  impend- 
ing, the  use  of  a  suppository  of  opium  and  belladonna  was  followed 
by  a  daily  well-formed  stool. 

*  See  Boas,  Diagnostik  u.  Therapie  d.  Magenkrankheiten,  4te  Aufl.,  1897,  Th.  1, 
S.  293  ;  and  von  Leube,  in  von  Leyden's  Handbuch  der  Ernährungstherapie,  1897, 
Bd.  i,  S.  490. 


414  DISEASES   OF   THE  INTESTINES 

Surgical  Treatment  of  Intestinal  Strictures 

As  already  remarked,  internal  medication  cannot  have  a  cura- 
tive effect  upon  an  intestinal  stenosis  unless  the  same  be  due  to  a 
foreign  body.  In  every  case  of  intestinal  stenosis  we  must  there- 
fore consider  the  advisability  of  operation.  The  question  of  the 
cause  of  the  stenosis  vs^ill  naturally  play  a  very  important  part  as  an 
indication.  A  malignant  tumour,  no  matter  where  situated,  offers 
a  worse  prognosis  than  a  cicatricial  stenosis  or  a  stricture  produced 
by  a  foreign  body — for  instance,  by  gallstones.  The  site  of  the 
stenosis  must  also  be  considered.  Owing  to  the  immobility  of  the 
duodenum,  a  carcinoma  of  its  superior  portion  can  scarcely  be  rad- 
ically extirpated,  while  tumours  of  the  ileum  or  of  the  colon  offer 
much  better  chances  of  complete  removal.  Benign  tumours,  though 
of  large  size,  are  generally  more  amenable  to  radical  treatment  than 
malignant  ones.  Extensive  adhesions  may  make  the  removal  of 
the  tumour  much  more  difficult,  and.  after  its  removal  may  cause 
intestinal  obstruction.  Autopsy  often  reveals  multiple  strictures, 
whereas  at  the  time  of  operation  but  one  stricture  was  found  and 
removed  (Hofmeister  and  others).  It  is  never  possible  therefore 
to  accurately  determine  beforehand  the  nature  of  the  operation  re- 
quired, or  its  result  and  the  prognosis. 

The  indications  for  operation  vary  with  the  individual  case. 
Generally  speaking,  benign  stenoses,  unaccompanied  by  marked  me- 
chanical disturbances,  are  best  treated  by  internal  methods,  while 
severe  stenoses,  in  which  internal  measures  have  been  exhausted, 
are  proper  subjects  for  surgical  treatment.  Mild  stenoses  of  a  ma- 
lignant nature  (tuberculous  and  carcinomatous)  belong  exclusively 
to  surgery.  In  these  cases  delay  may  be  fatal.  On  the  other  hand, 
we  have  seen  that  the  diagnosis  at  this  stage  of  the  disease  is  ex- 
tremely difficult.  Patients  with  a  beginning  stenosis  are  very  rarely 
willing  to  be  operated  on.  When  complete  obstruction  supervenes 
upon  stenosis  the  treatment  is  in  every  respect  the  same  as  that 
described  under  that  affection. 

II.  Treatment  of  Intestinal  Obstruction. 

"When  the  practitioner  is  confronted  with  a  case  of  intestinal  ob- 
struction he  ought  to  have  a  clear  idea  of  the  limitations  in  our 
knowledge  of  this  most  dangerous  form  of  intestinal  disease.  It 
would  be  of  incalculable  value  for  therapeusis  if  by  some  method 
similar  to  radiography  we  could  actually  see  how  an  intestinal  seg- 


INTESTINAL  OBSTRUCTION  415 

ment  is  cauglit  in  a  mesenteric  fenestrum,  or  how  a  peritoneal 
strand  causes  intestinal  strangulation,  or  how  an  angular  kinking  of 
the  bowel  is  produced  by  a  cheesy  degenerated  gland,  or  how  a  for- 
eign body  has  obstructed  the  intestinal  lumen.  We  could  then 
immediately  exclude  a  number  of  cases  in  which  internal  treatment 
is  useless.  These  are  the  mechanical  obstructions,  most  of  which 
can  only  be  removed  by  mechanical  means. 

Since  our  present  knowledge  does  not  enable  us  to  localize  or  to 
recognise  the  cause  of  the  obstruction  in  all  cases,  it  is  difficult  to 
lay  down  absolute  rules  for  the  physician's  guidance.  Is  internal 
treatment  absolutely  of  no  avail  from  the  very  beginning  of  the 
case,  or  shall  we  wait  ?  How  long  shall  we  wait  ?  Or  is  it  a  case  in 
which  we  can  expect  so  much  from  internal  treatment  that  surgical 
treatment  is  uncalled  for  ?  In  most  cases  it  is  scarcely  possible  to 
answer  these  questions,  and  therefore  our  treatment  must  be  some- 
what schematic.  We  would  not  have  it  inferred  that  all  cases  of 
obstruction  are  to  be  treated  alike.  On  the  contrary,  we  should  try 
to  individualize  as  much  as  possible. 

Internal  Treatment  of  Intestinal  Obstructions 

This  may  be  divided  into  dietetic,  mechanical,  and  medical 
measures. 

{a)  Diet. — Most  clinicians  agree  that  patients  with  intestinal 
obstruction  should  have  an  "  absolute  diet "  [withdrawal  of  all 
food]  (Goltdammer,  Curschmann,  Ewald,  I^othnagel,  etc.).  I  have 
already  expressed  myself  (page  152)  as  somewhat  averse  to  this 
opinion,  and  I  would  again  explain  my  views  on  this  subject.*  In 
my  opinion  the  diet  in  obstruction  of  the  large  intestine  must  be 
quite  different  from  that  in  obstruction  of  the  small  bowel.  As 
Curschmann  ^^  states,  feeding  jper  os  in  the  latter  disease  really  im- 
poses an  additional  burden  on  the  intestine,  and  hence  should  be 
limited  as  much  as  possible,  if  not  entirely  given  up.  It  is  different, 
however,  in  obstruction  of  the  large  intestine.  In  these  vomiting 
does  not  always  occur ;  when  present  it  is  not  usually  very  violent, 
and,  what  is  very  important,  it  very  rarely  becomes  faecal.  The 
view  often  expressed,  that  there  is  a  suspension  of  the  motor  and 
of  the  resorptive  power  of  the  intestinal  segment  lying  proximal  to 

*  Above  all,  we  must  discard,  the  idea  that  diet  is  of  secondary  importance  in 
intestinal  obstruction.  I  believe  that  patients  have  lost  their  lives  in  consequence 
of  this  misconception,  which  is  directly  opoosed  to  modern  views.  I  consider 
everything  of  calorie  value  consumed  by  the  patient  as  so  much  gain  for  him. 


416  DISEASES   OF  THE   INTESTINES 

the  obstruction,  is  true  of  the  small  intestine,  but  as  regards  the 
large  intestine  is,  so  far  as  I  can  see,  only  a  pure  hypothesis,  and 
has  never  been  experimentally  proved.  Accordingly,  it  is  entirely 
proper  to  have  patients  with  obstruction  of  the  large  bowel  con- 
sume as  much  easily  digested  nourishment  as  possible.  We  must 
proceed  carefully  and  cautiously,  and  be  led  by  the  course  of  the 
affection  in  each  individual  patient. 

The  nourishment  must  be  regulated  even  in  its  smallest  detail. 
It  should  be  a  fluid  or  a  semifluid  diet,  which  is  absorbed  without 
difficulty  in  the  upper  bowel  and  leaves  no  residue.  The  follow- 
ing are  particularly  to  be  recommended  :  Iced  milk,  beef  tea,  cau- 
dle, meat  jellies,  and  the  numerous  albuminoid  preparations  found 
in  the  market.  We  may  also  try  small  quantities  of  alcohol  in  the 
form  of  cognac,  Hungarian  wine,  sherry,  etc.  It  is  not  a  question 
of  a  great  nutritive  result,  but  when  we  consider  that  during  the 
course  of  treatment  an  operation  is  often  indicated,  we  must  never 
even  for  an  instant  forget  the  importance  of  stimulation  of  the 
heart,  and  of  giving  the  patient  large  quantities  of  fluid. 

When  from  the  onset,  or  from  attempts  already  made,  we  know 
that  patients  cannot  be  fed  by  the  mouth,  we  should  always  employ 
nutrient  rectal  enemata.  Where  for  mechanical  causes  the  enemata 
are  not  retained,  we  may  (as  recommended  by  Curschmann)  attempt 
to  obviate  the  threatening  systemic  loss  of  water  and  the  cardiac 
collapse  by  subcutaneous  injections  of  salt  and  sugar  solutions. 
Many  surgeons  appreciate  the  value  of  the  latter  procedure,  and 
before  beginning  operations  on  patients  with  cardiac  weakness  are 
in  the  habit  of  injecting  saline  solutions, 

(b)  Mechanical  Treatment. —  Gastric  lavage^  introduced  into  the 
therapy  of  intestinal  obstruction  by  Kussmaul  and  Cohn,  undoubt- 
edly is  the  most  valuable  of  our  mechanical  measures.  Its  effect  is 
to  lessen  the  pressure  above  the  occluded  segment  and  thereby  to 
remove  the  great  hindrance  to  compensation  of  the  obstruction. 
We  have  already  described  the  value,  indications,  and  technic  of 
stomach  lavage  (p.  184),  and  we  would  here  again  point  out  that 
this  procedure  is  indicated  only  in  cases  of  obstruction  of  the  small 
bowel.  Gastric  lavage  will  scarcely  ever  be  attended  by  any  great 
success  in  invaginations  of  the  large  bowel,  in  sigmoid  volvulus,  in 
internal  strictures  of  the  large  bowel,  in  dynamic  ileus,  in  obstruc- 
tion by  impacted  faeces  or  enteroliths. 

Under  certain  conditions  rectal  injections  may  favourably  influ- 
ence the  course  of  the  intestinal  obstruction,  only,  however,  when 


INTESTINAL   OBSTRUCTION  41Y 

the  latter  is  deeply  situated.  Invaginations  may  be  relieved,  im- 
pacted foreign  bodies  loosened,  and  incomplete  volvulus  occasion- 
ally reduced,  inspissated  fecal  masses  gradually  softened,  and  the 
paralytic  large  intestine  excited  to  peristalsis.  I  consider  thorough 
rectal  irrigations  with  soap  or  emulsified  oil  solutions  (see  p.  1Y9) 
most  appropriate.  We  must  naturally  not  expect  too  much  from 
these  procedures. 

A  few  observers  have  recommended  massage  in  intestinal  ob- 
struction. Except  perhaps  in  positive  obstruction  [!]  its  use  is  not 
sufficiently  clear.  Because  of  the  danger  of  peritonitis,  we  would 
further  recommend  the  greatest  caution  in  such  manipulations. 

Regarding  puncture  of  the  distended  intestine  by  the  Pravaz 
syringe,  opinions  are  very  much  at  variance.  This  procedure  has 
lately  been  recommended  particularly  by  Curschmann  ^^,  O.  Rosen- 
bach^*,  Fiirbringer  ^^,  von  Ziemssen^^,  and  others.  On  the  other 
hand,  it  has  been  condemned  by  almost  all  surgeons  ;  for  example, 
by  Treves,'^  Körte  ^^,  Graser,f  Kocher  ^^,  and  others.  Kocher  calls 
it  an  operation  in  the  dark. 

Curschmann  ®^  recommends  the  following  technic  for  puncture  of  the  bowel 
through  the  abdominal  wall :  A  long  needle,  having  a  valve  of  the  calibre  of  a 
Pravaz  aspirator,  is  thoroughly  disinfected.  After  the  valve  has  been  closed 
the  needle  is  passed  into  the  intestinal  coil  which  is  most  distended,  and  which 
in  each  case  must  be  most  carefully  sought  for.  The  needle  is  then  immedi- 
ately connected  with  a  rubber  tube,  the  latter  is  passed  into  a  bottle  containing 
a  watery  solution  of  salicylic  acid,  and  the  bottle  is  turned  over  a  basin  con- 
taining the  same  fluid.  When  the  valve  of  the  canula  is  opened  the  intestinal 
gases  rise  into  the  bottle,  at  first  in  a  continuous  stream,  later  more  slowly  in 
large  pearls,  finally  intermittently.  Fürbringer's  advice  not  to  hold  the  needle 
tightly,  but  to  allow  its  direction  to  be  guided  by  the  intestine  itself,  is  im- 
portant.    The  intestines  may  be  punctured  at  various  places. 

This  method  has  for  its  object  the  diminution  of  the  tension 
in  one  or  more  intestinal  coils,  thereby  allowing  the  incarcerated 
segment  to  free  itself  more  readily.  Curschmann  and  Fürbrin- 
ger  claim  to  have  seen  cures  from  the  procedure.  The  method 
requires  great  caution  and  should  only  be  used  in  selected  cases. 
It  is  only  indicated  in  cases  with  well-defined  distended  coils,  most 
frequently  in  strangulation  and  volvulus.  It  is  strongly  contraindi- 
cated  in  intestinal  paralysis,  in  invaginations,  in  peritoneal  irrita- 
tion, especially  when  a  tendency  to  gangrene  exists. 

*  Darmobstruction,  S.  446  u.  f.  [Intestinal  Obstructions,  p.  471  et  seq.]. 
f  Loc.  cit.,  p.  603. 


418  DISEASES  OF  THE  INTESTINES 

Inflation  with  air  has  practically  the  same  significance  as  ene- 
mata  of  water.  Many  cures  by  this  method,  particularly  in  invagi- 
nations, have  been  pubHshed.  Impacted  foreign  bodies  may  also  be 
removed  in  this  manner.  Finally,  inflation  with  air  may  tempora- 
rily or  permanently  relieve  intestinal  kinking.  In  intestinal  ulcera- 
tion and  peritonitis,  however,  it  is  strongly  contraindicated. 

Electrical  Treatment. — By  means  of  the  rectal  sounds  already 
described  (page  178)  the  faradic  or  galvanic  current  may  be  used  for 
the  relief  of  obstruction.  Both  currents  have  been  employed  with 
marked  success,  Yery  favourable  results  were  obtained  by  Bodet, 
of  Paris,  who  reported  53  cures  in  70  cases  (!).  In  France  electrical 
treatment  is  considered  of  extraordinary  value,  and  is  preferred  to 
opium,  Boudet^^  uses  the  galvanic  current  exclusively.  After  the 
rectum  has  been  filled  with  one  litre  of  salt  solution,  the  current  is 
applied  by  means  of  a  soft-rubber  sound,  which  in  its  interior  con- 
tains a  metallic  wire.  The  instrument  is  similar  to  the  rectal  sound 
described  on  page  174.  The  negative  pole  is  connected  with  the 
sound,  and  the  positive  pole  is  applied  to  the  abdomen  or  back  by 
means  of  a  broad  flat  plate  electrode.  The  current  applied  varies 
from  10  to  50  milliamperes,  and  each  application  should  last  from 
20  to  25  minutes.  We  would  naturally  hesitate  to  ascribe  to  the 
electric  current  such  marked  effects  in  the  removal  of  mechanical 
obstructions,  but  the  high  percentage  of  the  reported  cures  refutes  the 
objection  that  all  these  were  cases  of  faecal  impaction.  This  method 
deserves  more  consideration  in  Germany  than  it  has  heretofore 
received. 

(c)  Medicinal  Treatment. — Practically  this  is  limited  to  either 
laxatives  or  sedatives.  The  relative  value  of  these  two  classes  of 
remedies  has  been  in  dispute  for  more  than  a  century,  and  only 
within  the  last  ten  years  has  the  conclusion  been  reached  that  laxa- 
tives are  contraindicated  in  all  forms  of  obstruction  except  faecal 
impaction  and  paralytic  obstruction.  Heidenhain  ^"^  has  recently 
pointed  out  that  after  hernial  reduction  and  operations  for  intes- 
tinal obstruction  the  only  proper  treatment  consists  in  cleansing 
enemata  or  laxatives,  particularly  castor  oil.  In  this  we  fully  agree 
\vith  him. 

In  all  other  cases  treatment  by  laxatives  can  only  do  harm.  In 
a  case  of  chronic  invagination  reported  from  Kussmaul's  clinic  ^\  a 
dose  of  castor  oil  was  followed  by  marked  abdominal  pain  and  by 
rigidity  of  the  intussusception,  which  descended  to  the  anus.  After 
morphin,  on  the  contrary,  the  pains  not  only  decreased,  but  the 


INTESTINAL  OBSTRUCTION  419 

tumour  became  less  marked  and  the  invaginated  portion  retracted. 
When  we  consider  that  during  the  first  stage  of  occlusion  there  is 
an  attempt  to  overcome  the  presenting  obstacle  by  increased  peri- 
stalsis, it  is  evident  that  an  artificial  increase  of  these  efforts  is  en- 
tirely unnecessary  and  generally  harmful.  The  further  filling  of  the 
distended  intestine  above  the  obstruction  lessens  the  chances  of 
spontaneous  cure. 

With  the  exception  of  the  two  above-named  instances,  opiates 
spulvus  opii,  0.02  to  0.05  grams  every  three  or  four  hours,  or  morphin, 
0.01  to  0.03  [!]  grams)  act  effectually.  They  quiet  pain,  control  vio- 
lent peristalsis,  prevent  initial  shock,  diminish  vomiting,  induce  sleep, 
and  thus  favourably  influence  the  general  health.  Undoubtedly 
opium,  similar  to  digitalis,  is  a  tonic  in  heart  failure.  By  quieting 
the  intestines,  and  preventing  dragging  upon  the  inflamed  perito- 
neum, opium  acts  as  a  prophylactic  against  local  peritonitis,  which, 
according  to  present  views,  may  develop  in  the  first  stages  of  ob- 
struction. Opium  is  best  administered  in  the  form  of  suppositories 
(each  containing  0.05  grams),  or  subcutaneously  ( [extr.  opii]  0.01  to 
0.05  grams).  I  would  recommend  the  latter  method.  This  treat- 
ment, however,  has  its  indications  and  its  limitations.  I  repeat  that 
opium  is  to  be  used  only  in  the  first  stages  of  intestinal  obstruction, 
and  not  when  general  weakness  or  cardiac  paralysis  has  appeared. 
The  latter  instances  may  be  those  in  which,  as  some  surgeons  be- 
lieve, the  narcotic  temporarily  masks  the  serious  symptoms  of  ob- 
struction. This  justifies  the  advice  given  by  some  authors,  that 
after  the  therapeutic  effect  of  opium  has  been  obtained  one  should 
stop  its  administration  for  a  short  time,  so  that  the  actual  condition 
may  not  be  obscured  by  any  medicine.  Opium  is  also  strongly 
indicated  when  the  occlusion  is  complicated  by  local  or  general  peri- 
tonitis. Though  most  of  these  latter  cases  die,  opium  therapy  at 
least  presents  the  possibility  of  limiting  the  inflammation. 

Thus  we  possess  many  remedies  and  methods  for  the  internal 
treatment  of  obstruction.  So  far  as  I  can  see,  all  are  agreed  upon 
the  means  to  be  used,  but  not  upon  the  manner  of  their  adminis- 
tration. Some  advise  using  all  measures  at  one  time,  others  that 
they  be  used  in  rapid  succession.  I  believe  everything  depends 
upon  the  diagnosis.  For  example,  gastric  lavage  is  not  applicable  ■ 
to  sigmoid  volvulus  or  invagination ;  here  one  should  give  air 
insufflations  or  water  enemata.  Furthermore,  we  should  advise 
appropriate  diet,  methodical  opium  treatment,  and  always  use  the 
constant  electrical  current.     In  strangulation  of  the  small  bowel  we 


420  DISEASES   OF  THE  INTESTINES 

should  place  our  main  reliance  upon  opium  and  gastric  lavage.  The 
cardiac  power  may  be  increased  bj  small  rectal  enemata,  injections 
of  saline  solution,  etc.  We  should  make  it  our  duty  to  use  each 
remedy  systematically  and  persistently,  and  not  discard  one  method 
before  its  favourable  or  unfavourable  results  have  been  demon- 
strated. Misdirected  overtherapeusis  may  do  more  harm  than  care- 
fully planned  expectant  treatment. 

Surgical  Treatment  of  Intestinal  Obstruction 

IS'o  surgeon,  however  experienced,  can  in  every  case  of  intes- 
tinal obstruction  state  positively  whether,  and  at  what  moment,  an 
operation  may  be  necessary.  Even  if  his  judgment  in  one  or  more 
instances  was  correct,  the  very  next  case  might  demonstrate  that 
this  judgment  was  only  accidental. 

A  general  rule  of  procedure  must  be  the  result  of  principles 
derived  from  many  observations ;  but  even  then  it  is  almost  im- 
possible to  formulate  satisfactory  principles.  This  is  due,  above 
all,  to  the  variability  of  the  material  upon  which  the  private 
physician,  the  hospital  physician,  and  the  surgeon  must  base  their 
judgment.  In  the  majority  of  instances  the  surgeon  sees  only 
the  severest  cases  of  intestinal  obstruction  and  but  few  of  those 
which  have  been  cured  medicinally,  while  the  hospital  physician, 
and  more  especially  the  private  physician,  frequently  succeed  in 
curing  cases  by  conservative  treatment.  In  view  of  the  large 
number  of  cures  (33  to  35  per  cent,  according  to  fairly  well  agreed 
statistics),  and  of  the  rarity  of  obstruction  from  fsecal  impaction, 
the  objection  advanced  by  some  surgeons  that  these  are  only  cases 
of  simple  impaction  does  not  come  into  serious  consideration.  In 
which  forms  of  obstruction  do  medical  cures  occur  ?  They  un- 
doubtedly include  cases  of  feecal  tumour,  gallstone  obstruction,  in- 
vagination, and,  as  Curschman^  has  shown  by  autopsies,  kinking  of 
both  limbs  of  a  jejunal  coil  and  volvulus  of  the  sigmoid.  This 
2)roves  nothing  more  or  less  than  the  possibility  of  curing  even  severe 
forms  of  intestinal  obstruction  by  internal  therapeutics  (not,  hoio- 
ever,  as  some  surgeons  claim,  by  the  opium  therapeusis).  Thus  the 
extreme  view  of  a  few  surgeons,  that  every  case  of  mechanical  ob- 
struction requires  operation,  lacks  confirmation. 

It  is  certain,  however,  that  operative  procedures  have  saved 
many  lives  which  would  otherwise  have  been  lost.  From  statis- 
tics of  288  cases,  Naunyn  '^'^  has  demonstrated  that  the  earlier  the 
operation  the  better  the  results  obtained.     Of  those  operated  dur- 


INTESTINAL  OBSTRUCTION  421 

ing  the  first  two  days  of  the  disease,  Y5  per  cent,  and  of  those  oper- 
ated after  the  third  day,  35  to  40  per  cent,  were  cured.  These 
statistics  do  not  refer  to  all  cases  of  obstruction,  but  only  to  those 
which  were  operated  upon.  They  serve  to  emphasize  the  statement 
that  if  operation  is  to  be  performed  at  all  it  should  be  done  as  early 
as  possible. 

Since  the  results  of  internal  treatment,  though  not  exactly 
favourable,  are  by  no  means  hopeless,  they  may  be  compared  with 
those  following  operation.  If  we  consider  only  the  statistics  of 
individual  prominent  surgeons,  we  shall  find  that  the  results  of 
surgical  interference  are  not  particularly  encouraging.  Thus,  in 
about  110  cases  of  intestinal  obstruction,  Obalinski^^  had  a  mor- 
tahty  of  34.5  per  cent — just  as  large  a  death  rate  as  those  cases 
treated  internally.  Treves,*  who  reported  122  cases  of  laparotomy 
up  to  the  year  1888,  had  about  the  same  mortality,  36.9  per  cent. 
Even  Kocher^,  whose  results  in  abdominal  surgery  are  equal  to  any 
in  the  world,  had  as  high  a  mortality  as  38  per  cent.  Hence  we  may 
conclude  that  improved  antisepsis  and  technic  have  not  improved 
the  unfavourable  results  of  operation.  We  must  therefore  search 
for  another  factor.  In  his  discussion  on  intestinal  obstruction  (1889) 
Schede  has  spoken  so  convincingly  that  I  cannot  but  reproduce  his 
own  remarks :  "  Every  surgeon,  particularly  every  abdominal  surgeon, 
must  agree  with  me  that  these  operations  [for  obstruction],  if  per- 
formed upon  healthy  individuals,  would  only  very  rarely  end  fatally 
— in  5  per  cent,  or  at  most  10  per  cent,  of  the  cases.  But  there  is 
scarcely  any  other  condition  w^hich  so  rapidly  lessens  and  so  severely 
taxes  the  ability  of  a  patient  to  withstand  large  operations  and  long 
abdominal  manipulations  as  intestinal  obstruction.  A  few  days  are 
often  sufiicient  to  bring  about  a  condition  in  which  the  much- weak- 
ened patient  is  unable  to  bear  the  simplest  operation — for  example, 
the  search  for  and  division  of  a  pseudo  ligament." 

In  his  recent  treatise  Kocher  has  sought  for  the  conditions 
which  produce  these  unfavourable  results.  He  found  them  in  the 
changes  which  the  intestine  suffers  in  consequence  of  disturbances 
in  its  circulation.  The  epithelium  of  the  obstructed  segment  is 
destroyed,  allowing  micro-organisms  to  find  their  way  into  the  peri- 
toneum, and  cause  peritonitis.  Putrefying  substances  are  more 
easily  absorbed  from  a  mucous  membrane  denuded  of  its  ejDithe- 
lium,  hence  an  auto -intoxication  (or  sepsis)  results.      Kocher  has 

*  Darmobstruction,  S,  461. 
28 


422  DISEASES   OF   THE  INTESTINES 

likewise  called  attention  to  the  danger  of  perforation  from  ulcers 
whicli  develop  above  the  stricture  ("  distention  ulcers  "). 

The  chances  of  operative  success  are  also  considerably  lessened  by 
the  difficulty,  even  during  operation,  in  recognising  existing  condi- 
tions. Any  one  who  has  witnessed  the  efforts  and  the  time  required 
to  control  and  replace  the  distended  intestines  which  continually 
protrude  from  the  abdominal  cavity  will  understand  that  the 
strength  of  the  patient  is  often  exhausted  before  the  actual  opera- 
tion begins. 

In  addition,  it  is  often  impossible  before  operation  to  deter- 
mine the  site  or  the  type  of  obstruction. 

Where  shall  the  incision  be  made  ?  Which  intestinal  segment 
shall  be  sought  for  ?  Is  there  one  obstruction,  or,  as  occasionally 
happens,  are  there  several,  and,  in  the  latter  instance,  which  one 
occludes  the  bowel  ?  From  this  it  can  be  readily  understood  that 
the  suro-eon  is  often  confronted  with  insurmountable  difficulties. 

If  roe  are  to  draw  the  ])ro])er  conclusions  frora  this  discussion, 
we  TTiust  concede  that  the  results  and  da/ngers  of  internal  and  oper- 
ative treatment  are  alxmt  the  same.  In  any  given  case,  therefore,  it 
will  be  the  duty  of  the  physician  to  carefully  consider  which  method 
— operative  or  internal  treatment — offers  the  better  chances  for 
recovery. 

The  special  conditions  of  the  case,  the  kind  of  obstraction,  the 
age  and  strength  of  the  patient,  and  the  results  obtained  by  inter- 
nal therapy,  are  factors  to  be  considered.  The  sum  total  of  ex- 
periences reported,  favourable  as  well  as  unfavourable,  must  also 
influence  us  in  our  decision.  Regarding  this  point  the  following, 
statements  may  be  made : 

In  the  most  severe  forms  of  obstruction — strangidation  and 
incarceration — the  chances  of  cure  by  internal  measures  are  very 
small  indeed.  If  in  the  very  beginning  of  the  disease  the  symp- 
toms are  severe  and  the  clinical  signs  of  internal  strangulation  are 
present,  and  if  a  short  trial  with  opiates  and  gastric  lavage  has  been 
without  result,  operative  interference  is  undoubtedly  indicated. 

In  those  cases  of  obstruction  due  to  an  old  or  recent  external 
hernia,  the  indication  for  operation  is  also  very  clear.-  Statistics 
show  that  here  the  chances  of  cure  are  much  better  than  in  any 
other  form  of  obstruction.  According  to  Xaunyn,  72  per  cent  of 
the  cases  are  cured.  These  favourable  results  have  been  obtained 
because  the  diagnosis  can  frequently  be  made  before  operation,  and 
the  field  of  operation  is  limited. 


INTESTINAL   OBSTRUCTION  423 

In  gallstone  obstruction  the  results  are  not  so  satisfactory,  and 
we  must  be  more  guarded  in  our  jjrognosis.  The  chances  of  spon- 
taneous cure  are  comparatively  good  (according  to  Courvoisier,  56 
per  cent,  Lobstein,  52  per  cent,  ISTaunyn-Schiiler  and  Dufort,  44 
per  cent),  while  for  the  operated  cases  IS'aunyn  (23  cases)  reports 
a  mortahty  of  TO  per  cent,  and  Lobstein  (33  cases)  a  mortality  of 
60.1  per  cent. 

From  this  it  follows  that  surgical  treatment  of  gallstone  ob- 
struction does  not  as  yet  offer  such  favourable  results  that  operation 
ought  be  immediately  advised.  Since  the  symptoms  of  this  form 
of  obstruction  generally  develop  slowly,  we  should  first  carefully 
try  the  internal  therapeutic  measures  which  have  been  described. 
The  time  for  operation  must  be  decided  upon  in  each  individual 
case. 

Eegarding  operation  for  other  foreign  bodies  there  are  not  at 
present  sufläciently  extensive  statistics  from  which  to  draw  conclu- 
sions. It  is  a  well-known  fact  that  even  large  bodies  may  pass 
through  the  intestines  without  difficulty.  Since  in  the  majority 
of  these  cases  operation  is  followed  by  favourable  results,  we  should 
not  too  long  employ  internal  therapeutic  measures  if  intestinal 
obstruction  develops.  Obstruction  from  ascarides  (a  rare  form) 
may  also  demand  operation. 

Most  authorities  agree  that  as  soon  as  the  diagnosis  of  invagina- 
tion is  made  the  case  should  be  handed  over  to  the  surgeon.  Sta- 
tistics bear  out  the  complaint  of  surgeons  that  patients  with  invagi- 
nation are  generally  referred  to  them  too  late.  Barker ^^,  for  exam- 
ple, cured  7  out  of  11  cases,  a  result  which  he  declares  is  due  to  his 
operating  as  early  as  possible.  According  to  Gibson  ^,  who  in  his 
article  gave  a  table  of  all  cases  (239)  operated  on  up  to  the  year 
1896,  tlie  general  mortality  is  53  per  cent ;  in  those  oj)erated  on  on 
the  first  and  second  days  the  mortality  is  only  39  to  41  per  cent ;  on 
the  third  day,  62  per  cent ;  on  the  fourth  and  fifth  days,  72  per  cent ; 
and  on  the  sixth  day,  100  per  cent.  He  explains  these  differences 
by  the  fact  that  even  as  early  as  the  second  day  14  per  cent  of  the 
cases  are  already  irreducible ;  on  the  third  day,  38  per  cent ;  on  the 
fourth,  57  per  cent ;  and  on  the  seventh,  80  per  cent.  Gibson  gives 
the  proportion  of  deaths  in  the  reducible  and  irreducible  invagina- 
tions as  38  :  82.  The  age  of  the  patient  naturally  plays  a  great  part 
in  the  indication  for  operation.  Gibson's  statistics  show  a  mortality 
of  82  per  cent  in  jDatients  less  than  three  months  old  ;  the  mortality 
gradually  decreases  up  to  the  tenth  year,  when  it  is  37  per  cent, 


424  DISEASES  OF  THE  INTESTINES 

increasmg  again  to  the  fifteenth  year  (68  per  cent) ;  after  this  it 
approaches  the  adult  mortality  (62  per  cent). 

These  figures  show  that,  even  in  cases  operated  on  early,  the 
death  rate  from  invagination  is  considerable.  The  results  of  con- 
servative treatment  are  still  more  unfavourable. 

Since  the  above  statistics  demonstrate  that  early  operations  (up 
to  the  third  day)  offer  the  most  favourable  chances,  Tve  should  not 
continue  too  long  with  palliative  treatment.  Surgeons  state,  how- 
ever, that  palliative  treatment  should  not  be  entirely  neglected. 

For  example,  Eydygier^^,  in  his  latest  work,  recommends  non- 
surgical treatment  at  fii'st — electricity,  gastric  lavage,  rectal  enemata 
and  distention  with  gas  in  the  knee-chest  position,  massage,  and  at- 
tempts at  reduction  of  the  invagination  in  deep  narcosis.  Only 
when  one  or  all  of  these  measures  fail  is  operation  to  be  resorted  to. 

Chronic  invagination  is  somewhat  more  amenable  to  conserva- 
tive treatment,  and  the  appropriate  therapeutic  measures  may  for 
some  time  be  tried.  If  these  are  ineffectual  and  the  patient's  con- 
dition becomes  alarming,  it  is  best  to  operate  at  once.  According 
to  Eydygier's  rather  small  statistics,  the  mortality  from  operation 
is  only  24  per  cent. 

In  volvulus,  particularly  of  the  sigmoid,  the  indications  for  opera- 
tion are  different.  Xaunyn  ^  advises  delay  and  individual  consider- 
ation of  the  cases.  The  results  of  surgical  treatment  are  by  no 
means  excellent,  though  in  19  cases  of  volvulus  of  the  sigmoid  (in 
14  of  which  the  correct  diagnosis  was  made)  Obalinski  cured  10  by 
operation.  ISTothnagel  *  does  not  agree  with  ISTaunyn's  conclusions, 
and  pleads  for  active  interference  not  alone  in  severe  but  also  in 
mild  cases.  For  the  following  reasons  I  am  inclined  to  agree  with 
ISTothnagel.  It  is  not  particularly  difficult  to  diagnosticate  sigmoid 
volvulus,  the  surgeon  can  readily  find  the  obstruction,  and,  if  the 
volvulus  was  not  originally  incomplete,  the  chances  of  spontaneous 
reduction  are  very  small.  By  manipulations  through  the  rectum, 
we  shall  only  rarely  succeed  in  producing  a  permanent  cure.  On 
the  other  hand,  we  must  remember  that  the  symptoms  of  volvulus 
usually  develop  slowly,  that  there  is  usually  no  fsecal  vomiting,  and 
that  the  patient's  general  condition  remains  satisfactory  for  quite 
a  time.  Accordingly,  unless  the  disease  assume  an  exceptionally 
severe  course,  we  may  wait  two  or  three  days  for  a  spontaneous 
reduction.      If  within  this  time  this  has  not  occurred,  operative 


*  Darmkrankheiten,  S.  425. 


INTESTINAL  OBSTRUCTION  425 

interference  is  at  once  necessary.  If,  as  is  very  often  the  case,  a 
carcinoma  or  other  tumour  is  the  underlying  cause  of  the  volvulus, 
there  will  be  all  the  more  reason  for  surgical  interference,  since  by 
operation  we  not  only  relieve  the  volvulus,  but  also  may  remove 
its  cause.  A  spontaneous  reduction  will  not  permanently  cure  the 
condition,  as  the  volvulus  is  very  apt  to  recur. 

All  authorities  agree  that  the  surgical  is  the  only  proper  treat- 
ment for  internal  intestinal  strictures.  Since  these  generally  de- 
velop slowly,  the  question  of  operation  will  have  to  be  decided 
before  there  is  complete  intestinal  obstruction.  Whether  we  ought 
to  delay  or  immediately  take  active  measures,  Avill  depend  upon  the 
site  and  type  of  obstruction,  and.  particularly  upon  the  acuteness  of 
the  symptoms.  Even  should  spontaneous  cure  occur,  it  would  only 
be  a  respite,  hence  there  is  no  reason  for  long  delay.  It  is  true, 
however,  that  the  results  of  operations  for  tubercular  and  carcinom- 
atous strictures  are  only  temporary,  and  in  cases  of  multiple  stric- 
tures a  fatal  termination  is  unavoidable. 

Intestinal  obstruction  by  faecal  impaction  is  not  amenable  to 
surgical  treatment.  Here  the  internal  measures  already  described 
(purgatives,  rectal  injections  of  oil,  soap  and  water  irrigations, 
intestinal  faradization  or  galvanization)  are  in  place.  Unfortu- 
nately, the  diagnosis  is  often  so  extremely  difficult  that  an  operation 
may  be  necessary.  After  the  diagnosis  has  been  established,  even 
in  the  severe  forms,  internal  treatment  alone  is  indicated. 

Unless  the  intestinal  paralysis  is  reflex  in  character  (apparent 
reduction  of  external  hernia,  inflamed,  undescended  testicle,  etc.), 
and  its  cause  can  be  removed  by  operative  or  other  methods,  intes- 
tinal paralyses  are  to  be  treated  as  expectantly  as  jDossible.  A 
serious  result  may  often  be  averted  by  intestinal  irrigation,  electrici- 
ty and  purgatives.  If  these  do  not  succeed,  the  best  procedure  is 
the  formation  of  an  artificial  anus  as  high  up  as  possible. 

In  the  foregoing  we  have  described  the  indications  for  opera- 
tive treatment  of  intestinal  obstruction.  Discussion  of  the  opera- 
tive technic  belongs  rather  to  surgical  literature.*  We  shall  briefly 
call  attention  to  a  few  of  the  principal  points  involved. 

In  every  case  of  obstruction  the  aim  of  surgery  is  undoubt- 
edly to  remove  the  cause,  and  to  attempt  a  permanent  cure  by  lap- 
arotomy.    Unfortunately  there  are  often  exceptions  to  this  ideal 


*  An  excellent  resume  by  E.  Gräser  may  be  fouiul  in   Penzolclt  u.  Stintzing's 
Handbuch,  Bd.  iv. 


426  DISEASES   OF   THE  INTESTINES 

result.  Either  the  strength  of  the  patient  is  insufficient,  or  the  sur- 
roundings render  i-adical  operation  impracticable,  or  existing  condi- 
tions are  so  complicated  that  direct  removal  of  the  hindrance  is 
too  dangerous.  In  these  cases  enterostomy  is  the  operation  adopted 
by  almost  all  surgeons. 

In  the  Congress  for  Internal  Medicine,  1889,  Schede  ^^  warmly 
advocated  enterostomy.  From  his  experience  with  two  cases,  he 
pointed  out  that  the  formation  of  an  artificial  anus  might  not  only  be 
a  palliative  but  a  curative  operation.  On  the  other  hand,  von  Oet- 
tingen^^,  from  more  extensive  statistics,  showed  that  enterostomy  has 
not  been  successful  in  any  case  of  volvulus  with  axial  torsion,  or  in 
severe  incarceration  and  strangulation ;  but  that  it  had  succeeded 
in  intestinal  kinking.  In  acute  invaginations  also,  Eydygier^,  Gib- 
son ^^,  and  Ludloff^^  would  limit  the  formation  of  an  artificial  anus 
to  those  patients  whose  strength  does  not  allow  of  resection  of  the 
invagination.  If  the  condition  of  the  patient  improves,  a  radical 
operation  is  later  indicated. 

From  the  above  description  it  can  be  seen  that  there  is  a  distinct 
gap  between  the  therapeutic  principles  of  the  physician  and  of  the 
surgeon,  which  will  only  be  filled  when  the  number  of  surgical 
cures  becomes  much  greater  than  the  medical.  Excepting  with  a 
few  surgeons,  this  at  present  is  not  the  case.  The  changes  pro- 
duced in  the  obstructed  intestinal  segment  and  the  resulting  serious 
general  condition  develop  so  rapidly,  that,  to  employ  a  common 
expression,  the  surgeon,  even  though  operating  at  the  earliest  mo- 
ment, generally  operates  too  late. 

LITERATURE 

1.  Leichtenstern.     von  Ziemssen's  Handbuch,  Bd.  vii,  3,  2te  Aufl.,  S.  416. 

2.  Nothnagel.     Darmerkrankungen,  S.  189. 

3.  Wegele.     Münchener  med.  Wochenschr.,  1898,  No.  16. 

4.  Leichtenstern.     von  Ziemssen's  Handbuch,  Bd.  vii,  3,  S.  411  u.  418. 

5.  Cahn.     Berl.  klin.  Wochenschr.,  1886,  No.  23. 

6.  Riegel.     Zeitschr.   f.   klin.  Medicin,    1886,   Bd.  xi,   S.  187,   and    Deutsche 

med.  Wochenschr.,  1890,  No.  39. 

7.  Hochhaus.     Berl.  klin.  Wochenschr.,  1891,  No.  7. 

8.  Schule.     Ibid.,  1894,  No.  45. 

9.  Reiche.     .lahrb.  d.  Hamburger  Krankenanstalten,  1892,  Bd.  ii. 

10.  Herz.     Deutsche  med.  Wochenschr.,  1896,  No.  23  u.  24. 

11.  Pic.     Revue  de  medecine,  Dec.  1894,  et  Jan.  1895. 

12.  Rewidzoff.     Arch.  f.  Verdauungskrankheiten,  1898,  Bd.  iv,  S.  369. 

13.  Boas.     Deutsche  med.  Wochenschr.,  1891,  No.  28. 


INTESTINAL   OBSTRUCTION  427 

14.  Wilms.     Beiträge  z.  klin.  Chirurgie,  Bd.  xviii,  S.  2,  1897. 

15.  Boas.     Zeitschr.  f.  klin.  Medicin,  Bd.  xvii,  H.  1  u.  2,  1890. 

16.  Küttner.     Beiträge  z.  klin.  Chirurgie,  1899,  Bd.  xxiii,  H.  2,  S.  505.     (Here 

"will  be  found  the  literary  references  indicated  in  the  text.) 

17.  E.  Frankel.     Cited  from  Munch,  med.  Wochenschr.,  1896,   No.   28;  Mit- 

theilungen  aus  d.  Hamburger  Staatskrankenanstalten,  1897,  Bd.  i,  S.  61. 

18.  Hofmeister.     Beiträge  z.  klin.  Chirurgie,  1896,  Bd.  xvii,  S.  577. 

19.  Litten.     Zeitschr.  f.  klin.  Medicin,  Bd.  ii,  1881,  S.  702,  etc. 

20.  KnudFaber.     Berl.  klin.  Wochenschr.,  1897,  No.  30. 

21.  Johnson  and  Wallis.     Cited  by  K.  Faber  (reference  20). 

22.  F.  Treves.     Darmobstruction;  translated  by  Dr.  Arthur  PoUak.     Leipsic, 

1888,  p.  354.     [Intestinal    Obstruction;  its  Varieties,  etc.     New  York, 
1899,  p.  294.] 

28.  Rosenstein.     Berl.  klin.  Wochenschr.,  1881. 

24.  Jaccoud.     Traite  de  pathologic  interne. 

25.  Briquet.     Traitö  clinique  et  th6rapeutique  de  Thysterie.     Paris,  1859. 

26.  Leichtenstern.     Verhandlungen  d.    Congresses   f.    innere    Medicin,    1889. 

(Cited  from  a  report.) 

27.  Küttner.     Virchow's  Archiv,  1868,  Bd.  xliii. 

28.  Hilton  Fagge.     Guy's   Hosp.  Rep.,  vol.  xiv,   1869.     (Cited  from  Naunyn, 

Grenzgebiete  d.  Chirurgie  u.  Medicin,  vol.  i.) 

29.  von  Wahl.     Centralbl.  f.  Chirurgie,  1889,  S.  155;  Archiv  f.  klin.  Chirurgie, 

1889,  Bd.  xxxvüi,  S.  283. 

80.  Kader.  Centralbl.  f.  Chirurgie,  1891,  Beilage,  S.  110;  Inaug.-Diss.,  Dor- 
pat,  1891;  Arch.  f.  klin.  Chirurgie,  1891,  Bd.  xlii;  Deutsche  Zeitschr.  f. 
Chirurgie,  Bd.  xxxiii. 

32.  von  Zöge-Manteuffel.     Verhandl.  des  8.  Congresses  f.  innere  Medicin,  1889, 

S.  93. 

33.  Schede.     Verhandl.  des  8.  Congresses  f.  innere  Medicin,  1889,  S.  103. 

34.  Fenwick.     Obscure  Diseases  of  the  Abdomen.     London,  1889. 

35.  Schlange.     Archiv  f.  klin.  Chirurgie,  1889,  Bd.  xxxix,  S.  429;  Volkmann's 

Sammlung  klin.  Vorträge,  1894,  N.  F.  No.  101. 

36.  Obalinski.     Arch.  f.  klin.  Chirurgie,  1896,  Bd.  xlviii,  H.  1. 

37.  Naunyn.     Mittheil,  aus  d.  Grenzgebieten,  1895,  Bd.  i,  S.  98. 

38.  Tietze.     Deutsche  Zeitschr.  f.  Chirurgie,  1897,  Bd.  xlv,  H.  1  u.  2,  S.  17. 
89.  Englisch.     Oesterr.  medicin.  Jahrbücher,  1884,  No.  2  u.  8. 

40.  Frank.     Berl.  klin.  Wochenschr.,  1887,  No.  38. 

41.  von  Engel.     Prager  medicin.  Wochenschr.,  1899,  No.  14. 

42.  Israel.     Berl.  klin.  Wochenschr.,  1892,  No.  1. 

43.  Curschmann.     Verhandl.  des  8.  Congresses  f.  innere  Medicin,  1889. 

44.  Leichtenstern.     Berl.  klin.  Wochenschr.,  1874,  No.  40. 

45.  P.  Guttmann.     Deutsche  medicin.  Wochenschr.,   1884,  No.  14;  Berl.  klin. 

Wochenschr.,  1893,  No.  2. 

46.  Karl  Abel.     Berl.  klin.  Wochenschr.,  1894,  No.  4  u.  5. 

47.  Melchioris.     Cited  from  Treves,  Darmobstruction,  p.  142. 

48.  Cursclimann.     Deutsches  Arch.  f.  klin.  Medicin,  Bd.  liii,  H.  1  u.  2,  S.  1. 

49.  Böttcher.     Virchow's  Archiv,  1886,  Bd.  civ. 

50.  Fleiner.     Ibid.,  1885,  Bd.  ci. 


428  DISBASES  OF  THE  INTESTINES 

51.  Eaffinesque.     l^^tude  sur  les  invaginations  intestinales  chroniques.     These 

de  Paris,  1878. 
53.  D'Arcy  Power.     Some  Points  in  the  Anatomy,  Pathology,  and  Surgery  of 

Intussusception.     London,  1898. 

53.  Leichtenstern.     Prager  Vierteljahrsschrift,  Bd.  cxviii. 

54.  Henoch.  Kinderkrankheiten.     Berlin,  1881,  S.  453. 

55.  Kelling.     Arch.  f.  Verdauungskrankheiten,  1895,  Bd.  i,  H.  2,  S.  172. 

56.  Westphalen.     Ibid.,  1898,  Bd.  iv,  H.  1,  S.  63. 

57.  Kiedel.     Mittheil,  aus  d.  Grenzgeb.  d.  Medicin  u.  Chirurgie,  Bd.  ii,  S.  528. 

58.  Schnitzler.     Wiener  klin.  Rundschau,  1895,  No.  37. 

59.  L.  Meyer.     Virchow's  Archiv,  Bd.  xcv. 

60.  Mikulicz.     Arch.  f.  klin.  Chirurgie,  1895,  Bd.  li. 

61.  Körte.     Arch.  f.  klin.  Chirurgie,  1893,  Bd.  xlvi,  S.  331. 

62.  E.  Lobstein.     Beiträge  zur  klin.  Chirurgie,  1895,  Bd.  xiv,  S.  394. 

63.  Kirmisson-Rochard.     Archives  generales.     Mars,  1892. 

64.  Sick.     Deutsche  medicin.  Wochenschr.,  1891,  S.  368. 

65.  Köstlein.     Würtemb.  Corresj)ondenzbl.,  1876,  No.  6. 

66.  Dessauer.     Virchow's  Archiv,  Bd.  Ixvi,  S.  271. 

67.  Maclagan.     Lancet,  vol.  i,  p.  123,  1888. 

68.  Courvoisier.     Casuistisch  stat.  Beiträge  zur  Pathol,  u.  Chirurgie  d.  Gallea- 

wege.     Leipzig,  1890. 

69.  Down.     Quoted  from  Treves's  Darmobstruction,    S.    336   [and   Intestinal 

Obstructions,  p.  197]. 

70.  Davaine.     Traite  de  l]ntozoaires  et  de  maladies  ver-mineuses.     2"^  edit., 

Paris,  1871. 

71.  Heller.     Darmschmarotzer.     Ibid.,  S.  586. 

73.  Mosler  u.  Peiper.     Thierische  Parasiten.     Nothnagel's  Handbuch,  Bd.  vi, 
1894,  S.  197. 

73.  Heidenreich.     Semaine  medicale,  1891,  No.  42. 

74.  Simon.     Revue  medic,  de  I'Eto,   1892,   No.   8.     (Cited  from  Mosler  and 

Peiper.) 

75.  Frikker.     Deutsche  medicin.  Wochenschr.,  1897,  No.  4. 

76.  von  Leube.     Naturforscherversammlung  in  Düsseldorf  (from  report  in  the 

Munch,  med.  Wochenschr.,  1898,  No.  41). 

77.  Strauss.     Berl.  klin.  Wochenschr.,  1898,  No.  38. 

78.  Sandoz.     Correspondenzbl.  f.  Schweizer  Aertze,  1887,  S.  41. 

79.  Strehl.     Deutsche  Zeitschr.  f.  Chirurgie,  1899,  Bd.  Ivi,  H.  5  u.  6. 

80.  Grundzach.     Wiener  medicin.  Presse,  1895,  No.  10. 

81.  Hochenegg.     Wiener  klin.  Wochenschr.,  1897,  No.  51. 

83.  Gräser.     Penzoldt-Stintzing's  Handbuch  d.  speciellen  Therapie,  Ite  Aufl., 
Bd.  iv,  S.  568. 

83.  Curschmann.     Reference  43  ;  also  Deutsche  medicin.  Wochenschr.,  1887, 

No.  31. 

84.  O.  Rosenbach.     Ibid. 

85.  Fürbringer.     Verhandl.  des  8.  Congresses  f.  innere  Medicin,  1889. 

86.  von  Ziemssen.     Ibid. 

87.  Körte.     Berliner  Klinik,  1891,  No.  36. 

88.  Kocher.     Mittheil,  aus  d.  Grenzgebieten,  1898,  Bd.  iv,  S.  3. 


INTESTIN'AL  OBSTRUCTION  429 

89.  Boudet  (de  Paris).     Progres  medical,  7  et  14  Fevrier,  1885. 

90.  Heidenhain.     Deutsche  Zeitschr.  f.  Chirurgie,  1897,  Bd.  xliii,  S.  201. 

91.  Asch.    Inaug.-Diss.,    Strassburg,   1880.      (Cited   from  Gräser  in  Penzoldt- 

Stintzing's  Handbuch,  1.  Aufl.,  Bd.  iv,  S.  596.) 
93.  Barker.     Quoted  from  Ludloflf,  Grenzgebiete,  1898,  Bd.  iii,  H.  5,  S.  603. 

93.  Gibson.     New  York  Med.  Record,  July  17,  1894. 

94.  Rydygier.     Deutsche  Zeitschr.  f.  Chirurgie,  1896,  Bd.  xlii. 

95.  Schede.     Archiv  f.  klin.  Chirurgie,  Bd.  xxxvi,  H.  3. 

96.  von  Oettingen.     Inaug.-Diss.,  Dorpat,  1888. 


CHAPTEK  XIX 

TYPHLITIS,  PERITYPHLITIS   [APPENDICITIS) 

Preliminary  Hemarks. — Typhlitis  is  an  inflammation  of  tlie 
csecum  and  the  surrounding  peritoneum.  Perityphlitis  or  appen- 
dicitis* is  an  acute  or  chronic  inflammatory  process,  which  origi- 
nates in  the  vermiform  appendix,  and  may  remain  strictly  local- 
ized or  spread  to  the  surrounding  parts. 

At  the  present  day  we  believe  that  in  these  inflammatory  affec- 
tions the  csecum  is  much  less  involved  than  the  appendix.  Thus 
the  long-forgotten  teachings  of  Louyer,  Viller,  ]S~ay  (1824),  Melier 
(1827),  Grisolle,  and  others,f  which  were  so  obstinately  and  success- 
fully opposed,  are  now  vindicated.  From  Talamon  we  gather  that 
Melier  had  evidently  foreseen  the  possibility  of  removing  a  diseased 
appendix.  He  plainly  stated :  "  If  it  were  possible  to  diagnose 
these  affections  with  certainty  we  might  conceive  of  the  possibility 
of  curing  them  by  means  of  operation.  Perhaps  some  day  this 
result  may  be  achieved." 

Only  very  recently  have  the  old  mistaken  views  concerning 
appendicitis  been  overthrown.  To  a  very  great  extent  this  advance 
is  due  to  modern  surgery.  As  in  many  branches  of  gastro-intestinal 
diseases,  here  also  the  autopsy  in  vivo  and  jpost-mortem  have  borne 
rich  fruit  (Ribbert,  Zuckerkandl,  Matterstock,  H.  Einhorn,  and 
others).  Internal  medicine  slowly  yielded  to  modern  views,  and 
has  since  added  considerably  toward  extending  this  new  field.     The 

*  We  will  employ  the  terms  perityphlitis  and  appendicitis,  though  the  latter  is 
etymologically  not  exactly  correct.  Because  of  its  peculiar  pronunciation,  skoli- 
koiditis  (from  CKdiKr]^,  worm),  the  name  introduced  by  Nothnagel,  will  prob- 
ably not  come  into  general  favour.  The  term  epityphlitis,  recently  suggested  by 
Küster,  though  sounding  better  than  skolikoiditis,  is  also  objectionable,  since  the 
appendix  is  not  always  upon,  but  may  be  behind,  below,  above,  or  to  the  side  of 
the  Ciecum. 

f  Compare  the  interesting  historical  development  of  this  question  by  Talamon, 
Appendicite  et  Perityphlite,  Paris.  1892  ;  and  by  Grobe,  Pathologie  und  Therapie 
der  Perityphlitiden,  Greifswald,  1896. 
430 


TYPHLITIS,  PEKITYPHLITIS  (APPENDICITIS)  431 

excellent  article  of  SaLli^  and  the  impressive  discussion  pertaining 
thereto  have  accomplished  much  toward  this  end. 

Surgery  soon  dominated  this  new  field.  In  the  middle  of  the 
eighties,  with  the  progress  and  development  of  aseptic  methods, 
the  operative  treatment  of  appendicitis  made  rapid  advance  in 
England  and  America,  and  soon  obtained  brilliant  results. 

Gradually  our  ideas  of  this  affection  became  moderated,  and  the 
early  radicalism  was  somewhat  modified.  Indications  for  internal 
and  for  operative  treatment  began  to  be  compared,  the  results  of  in- 
ternal and  surgical  treatment  given  their  proper  value,  and  the  occa- 
sional bad  effects  of  the  operation  (fistulse,  abdominal  sinuses,  her- 
nise,  adhesions,  etc.)  were  considered.  Both  scientifically  and  prac- 
tically appendicitis  was  made  the  boundary  between  medicine  and 
surgery.  Before  proceeding  to  a  consideration  of  the  diagnosis 
and  treatment  of  this  affection  we  shall,  in  what  follows,  state  as 
briefly  as  possible  its  present  status,  in  so  far  as  it  concerns  the  clin- 
ical view  of  the  disease. 

Typhlitis. — Does  it  really  exist  ?  Has  stercoral  typhlitis  the 
significance  attributed  to  it  since  Alber's  time  ?  Yiews  differ ;  a 
few  authors  (among  the  modern  writers  I  cite  only  Talamon*) 
go  so  far  as  to  deny  the  occurrence  of  typhlitis.  We  may  discuss 
these  conditions  in  various  ways — e.  g.,  by  referring  to  pathological 
anatomy,  to  clinical  observations,  or  to  the  results  of  the  many 
surgical  operations. 

Pathological  anatomy  has  long  dealt  with  inflammatory  processes 
of  the  caecum.  Ulcerative  conditions,  particularly,  have  been 
known  since  autopsies  have  been  systematically  performed.  Usually, 
however,  these  ulcerative  conditions  were  quite  different  from  those 
now  in  question.  They  were  either  typhoid,  dysenteric,  tubercular, 
stercoraceous,  or  actinomycotic.  As  already  pointed  out  in  the 
more  extensive  discussion  of  these  ulcerations,  they  are  by  no  means 
limited  to  the  caecum,  but  occur  as  often  in  the  rectum,  the  flexures 
of  the  colon,  and  the  sigmoid  flexure.  Indeed,  it  is  surprising  that, 
excepting  the  rare  cases  of  pericolitis  and  sigmoiditis,  inflammatory 
processes  similar  to  typhlitis  are  not  found  more  often  in  other 
segments  of  the  large  intestine.  Etiologically,  besides  ulcerations, 
we  must  also  consider  foreign  bodies  (needles,  etc.)  and  neoplasms 
(particularly  cancerous  and  tubercular). 

What  is  the  status  of  clinical  teaching  regarding  typhlitis  ?     The 

*  Loc.  cit. 


432  DISEASES  OF   THE  IXTESTmES 

symptoms  of  typhlitis  are  described  as  follows :  Obstinate  constipa- 
tion, tympanites,  pain  and  sensitiveness  in  the  right  iliac  fossa, 
development  of  a  sausage-shaped  faecal  tumour  corresponding  to  the 
l^osition  of  the  csecum  {boudin  stercoral)^  moderate  fever,  and 
increased  indicauuria.  A  perforation  of  the  caecum  may  occur,  and 
death  from  peritonitis  follow. 

It  must  be  admitted  that  in  itself  this  picture  is  characteristic, 
but  modern  research  has  shown  that  it  cannot  be  distinguished 
from  disease  processes  which  originate  in  the  appendix.  There 
is  not  one  symptom  which  might  not  also  be  present  in  an  ap- 
pendiceal inflammation.  We  cannot  jpresent  an  absolutely  indi- 
'vidualizing  picture  of  typhlitis,  and  at  the  present  time  it  is  impos- 
sible to  syinptomatologiccdly  separate  appendicitis  and  typhlitis. 
The  results  of  operations,  however,  or,  as  I^othnagel  once  appropri- 
ately called  it,  the  results  of  "  biopsy,"  can  only  determine  the  diag- 
nosis during  life. 

Increased  observations  have  demonstrated  that,  though  rarely, 
isolated  inflammatory  processes  may  affect  the  caecum  or  its  vicinity 
^vithout  involving  the  appendix.  Such  observations  have  been 
reported  by  Harley^,  Mariage^,  Curschmann  "^5  Lennander^,  Porter^, 
Ivrönlein  '^,  Menley  ^,  Meusser  ^,  and  others.  I  agree  with  Borchardt^*' 
that  some  of  these  observations  will  not  stand  critical  investigation, 
but  among  these  there  are  several  (I  will  only  mention  the  case  of 
Lennander,  where  no  appendix  at  all  was  to  be  found)  which  need 
no  forced  interpretation,  and  which  prove  the  occurrence  of 
typhlitis.* 

The  etiology  of  typhlitis  shows  certain  variations.  There  may 
be  faecal  impaction  with  suppuration,  or  there  may  be  adhesions ; 
sometimes  there  are  ulcerations  of  the  most  varied  kinds,  with 
more  or  less  evident  perforations.  These  variations  prove  that 
typhlitis  by  no  means  gives  the  simple  clinical  picture  that 
appearances  would  warrant.  It  is  necessary  to  give  up  the  idea 
of  a  purely  stercoraceous  typhlitis,  for  impacted  faeces  per  se 
rarely  produce  typhhtis;  foreign  bodies,  ulcerations,  adhesions, 
and  fixation  of  the  ccecum  may  also  cause  inflammation  of  the 
caecum. 


*  Grohe  (loc.  cit.)  also  reports  an  observation  which  belongs  here.  In  a  paralytic 
wlio  died  of  broncho-pneumonia,  the  cfecum  was  filled  with  ffecal  masses.  In  the 
portion  of  the  intestinal  wall  opposite  the  mesenteric  attachment  there  was  found 
a  slight  ulceration  of  the  mucous  membrane  of  the  size  of  a  half  dollar,  which 
could  only  be  explained  by  faecal  impaction. 


TYPHLITIS,  PERITYPHLITIS   (APPENDICITIS)  433 

Perityphlitis  (Appendicitis). — It  is  now  an  absolutely  estab- 
lished fact  that  the  inflammatory  processes  which  start  in  the  ap- 
pendix greatly  preponderate,  and  that  the  great  majority  of  dis- 
eases until  recently  designated  as  tyjMitis,  perityphlitis,  atid para- 
typhlitis likeioise  originate  in  the  vermiform  apjjendix.  This  fact 
is  supported  not  only  by  anatomical  observations  (Matterstock,  Fen- 
wick,  H.  Einhorn),  but  also  by  the  great  number  of  observations  of 
the  foremost  surgeons  (Eoux,  Sonnenburg,  Kümmel!,  Lennander, 
Körte,  Schede,  Eotter,  McMurtry,  Reginald  Fitz,  McBurney, 
Fowler,  Treves,  Beck,  Kelynack,  Dunn,  and  others).  The  abso- 
lute agreement  of  these  surgeons  relieves  us  of  the  necessity  of 
presenting  isolated  statistics.  The  question  arises  as  to  which  are 
the  most  frequent  causative  factors. 

To  answer  this,  a  brief  anatomical  description  of  the  relation 
and  position  of  the  appendix  is  necessary. 

The  length  of  the  appendix  varies  from  2^  to  24  centimetres,  the  average 
being  about  9  centimetres.  Its  thickness  is  about  that  of  a  goose  quill.  In 
the  newly  born  the  proportion  of  the  length  of  the  appendix  to  th'e  large  intes- 
tine is  as  1  to  10;  in  the  adult,  1  to  20.  Like  the  caBCum,  the  appendix  has 
a  mesentery  (mesenteriolum,  mesovermium)  in  which  the  nourishing  blood  and 
lymph  vessels  course.  The  caecal  artery,  the  lowest  offshoot  of  the  superior 
mesenteric,  gives  off  a  branch  to  the  mesovermium — the  appendicular  artery; 
the  latter  runs  along  the  mesentery  parallel  to  and  a  few  millimetres  away  from 
the  appendix,  giving  off  branches  to  that  organ.  The  appendicular  artery  is  a 
terminal  artery  (in  Cohnheim's  sense),  and  this  accounts  for  the  severe  changes 
which  may  develoji  in  the  course  of  apparently  mild  cases  of  appendicitis.  The 
mucous  membrane  of  the  appendix  contains  cylindrical  cells,  Lieberkuhn's 
glands,  blood  and  lymph  vessels,  and  is  distinguished  from  the  other  intestinal 
segments  by  its  striking  abundance  of  lymph  follicles.  According  to  Ribbert  '^ 
the  latter  vary  very  much  with  the  age.  In  childhood  the  lymph  follicles  are 
very  large  and  lie  closely  together;  after  the  twentieth  year  they  decrease  in 
size  and  become  more  separated. 

At  the  insertion  of  the  appendix  the  so-called  valve  of  Gerlach,  or,  accord- 
ing to  Groh6,  more  properly  the  valve  of  Merling,  is  sometimes  present,  though 
frequently  absent  (Clado,  Lafforgue).  This  structure,  however,  cannot  prevent 
faeces  from  passing  into  the  appendix. 

Being  a  functionally  unnecessary  organ,  the  appendix  presents  involution 
changes  with  increasing  age  (Ribbert).  After  disappearance  of  the  epithelium 
there  develops  a  slow  proliferation  of  the  connective  tissue  of  the  mucosa,  while 
the  submucosa  and  muscularis  retain  their  structure.  By  this  process  the  lumen 
of  the  appendix  becomes  gradually  narrowed,  and  in  one  third  of  all  cases 
absolutely  obliterated. 

The  relation  of  the  peritoneum  is  important  to  an  understanding  pf  the 
anatomical  changes.  As  modern  observation  (Bardeleben,  Luschka,  Tuffier) 
has  shown,  the  entire  circumference  of  the  caecum  is  covered  by  peritoneum,  so 


434:  DISEASES  OF  THE  INTESTINES 

that  in  more  than  96  per  cent  of  all  cases  the  appendix  lies  intraperitoneally 
(Maurin  --,  Bryant ",  F.  Yon  Sydow ").  The  appendix  may  accompany  the 
caecum  in  its  various  changes  in  position.  We  ^'ill  discuss  this  point  more 
fully  in  the  diagnostic  section. 

The  manner  of  attachment  of  the  appendix  to  the  csecum  is  of  great  surgical 
interest,  and,  as  Krausshold  '^  has  long  since  shown,  may  vary  considerably. 
The  most  frequent  insertions  of  the  appendix  are  internally  to,  behind,  below 
and  in  front  of  the  caecum,  and  finally  in  the  small  pelvis  (Bryant). 

Tlie  causes  of  aj)pendicitis  are  direct  and  ^predisposing. 

Of  the  direct  causes  fsecal  concretions  play  an  important  part. 
According  to  Ribbert  ^^  they  occur  in  10  per  cent  of  appendicitis ; 
according  to  Kenvers  ^^,  Treves  ^^,  and  Murphy  ^^  in  about  one  third 
of  all  cases ;  according  to  some  authors  (Matterstock)  they  produce 
50  per  cent  of  the  cases. 

Other  foreign  bodies  are  found,  but  they  are  more  rare  than 
coproliths,  being  present  in  about  2  per  cent  of  all  cases. 

The  presence  of  fsecal  concretions  (which,  by  the  by,  have  only 
a  central  nucleus  of  faeces,  the  remainder  consisting  of  several  layers 
of  mucus  (Ribbert  ^^)  ),  by  no  means  explains  the  entire  etiology  of 
appendicitis,  for  there  are  many  cases  in  which  these  concretions 
are  not  present,  but  in  which  the  appendix  contains  mucus  or  fluid 
faecal  masses.  In  view  of  this,  we  must  ask  whether  faecal  con- 
cretions really  play  a  considerable  part  in  the  etiology,  or  only 
favour  the  development  of  an  inflammation.  This  question  has 
been  variously  answered.  In  my  opinion  the  concretion  acts  only 
as  a  predisj)osing  factor  in  conjunction  with  other  conditions  soon 
to  be  considered. 

We  have  already  described  the  peculiar  structure  of  the  appen- 
dix, its  abundance  of  lymph  follicles,  the  absence  of  smooth  muscle 
fibres,  its  extraordinary  length  in  proportion  to  its  narrow  lumen, 
its  tendency  to  changes  of  position  and  form,  and,  finally,  the  ab- 
sence of  anastomoses  in  the  appendicular  artery.  All  these  circum- 
stances favor  catarrhal  inflammation,  which,  no  matter  what  its 
cause,  leads  to  increase  and  stagnation  of  secretion. 

The  chief  cause  of  appendicitis  without  doubt  lies  in  the  stagna- 
tion of  its  secretion.  The  pathology  of  other  organs  demonstrates 
the  harmful  effect  of  stagnating  secretions  in  hollow  viscera.  In 
the  gastro-intestinal  canal  they  are  the  main  cause  of  severe  nutri- 
tive disturbances;  in  the  gall  bladder  they  are  to  a  great  extent 
responsible  for  formation  of  stones ;  and  in  the  course  of  a  surgical 
wound  the  absence  of  sufficient  flow  of  secretion  constitutes  one  of 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  435 

the  most  important  complications.  -Evidently  all  this  also  applies 
to  the  appendix.  As  long  as  there  is  free  and  regular  communica- 
tion between  the  mucous  membrane  of  the  appendix  and  caecum, 
even  though  virulent  bacteria  be  present,  no  disturbance  will  fol- 
low. The  moment,  however,  the  communication  ceases,  and  the 
outflow  of  secretion  is  prevented  either  by  faecal  concretions,  ca- 
tarrhal swelling,  partial  obliteration,  or  by  compression  or  adhesion 
of  neighbouring  organs,  decomposition  of  the  contents,  inflamma- 
tion, ulceration,  gangrene,  and  suppuration  occur. 

As  demonstrated  by  the  careful  studies  of  Tavel  and  Lanz^^, 
Eckehorn^",  Morris  ^^,  and  others,  bacteria,  especially  the  bacterium 
coli  communis,  undoubtedly  play  a  prominent  part  in  the  above 
processes.  The  destructive  powers  of  the  bacteria  are  only  exer- 
cised when  a  favourable  medium  for  considerable  development,  and 
perhaps  also  for  their  transplantation,  is  offered. 

As  already  mentioned,  this  medium  is  furnished  by  the  stagna- 
tion of  secretion,  by  loss  of  epithelium,  by  erosions,  or  by  catarrhal 
or  pressure  ulcerations,  which,  owing  to  the  poor  blood  supply  of  the 
appendix,  develop  only  too  easily. 

If,  therefore,  the  faecal  concretions  are  given  their  proper,  rather 
large  predisposing  part  in  the  etiology  of  perityphlitis,  and  if  we  do 
not  underestimate  the  influence  of  the  bacteria  natural  to  the  appen- 
dix, the  direct  development  of  the  inflammatory  process  must  be 
sought  for  in  the  peculiar  anatomical  form  and  structure  of  the 
appendix,  M^hich  produce  and  make  possible  the  deleterious  action 
of  both  the  above  factors. 

Another  circumstance  which  speaks  in  favour  of  the  above  view 
is  the  inf requency  of  perityphlitis  in  childhood.  In  the  statistics  of 
Matterstock,  of  474  cases  of  perityphlitis,  there  are  only  46  cases 
between  the  ages  of  one  and  ten  years.  Out  of  228  cases  Fitz 
gives  22  of  the  latter  age,  and  out  of  130  Sonnen  burg  only  26. 
Still  more  convincing  are  the  statistics  of  the  pediatrists.  From 
the  excellent  monograph  of  Karewski^^  on  perityphlitis  in  child- 
hood, we  tind  that  Henoch,  during  the  years  1890-1894,  among 
3,486  sick  children,  saw  only  2  cases  of  appendicitis.  Baginsky,  in 
1890-1891,  of  494  cases,  saw  none ;  of  415  cases  in  1891-1892  he 
also  observed  none;  of  1,692  cases  in  1892-1893,  he  observed  but 
3  ;  in  1893-1894,  of  2,234  cases,  only  4;  in  1895,  of  2,580,  8  peri- 
typhlitis cases ;  altogether  15  cases  out  of  a  total  of  7,413  diseased 
children. 

Again,  from  H.  Einhorn's  statistics  from  the  Pathological  Insti- 


436  DISEASES  OP  THE  INTESTINES 

tute  of  Munich,  the  number  of  cases  of  perityphlitis  in  proportion 
to  total  autopsies  was  5  per  1,000,  the  cases  in  children  being  2  per 
1,000.  Since  the  diagnosis  of  this  affection  in  children  is  quite 
difficult,  this  proportion  is  rather  too  large  than  too  small.  In  this 
connection  Nothnagel's^^  statistics  are  also  of  great  value.  Of 
44,94:0  autopsies  performed  in  the  Vienna  General  Hospital  in  the 
years  18Y0  to  1896,  there  were  148  cases  of  peri-  and  paratyphlitis 
(0.3  per  cent).  Of  these  148  cases  only  2  were  in  children  between 
one  and  nine  years  of  age. 

The  explanation  of  these  facts  is  furnished  by  the  investigations 
of  Steiner^*,  Ribbert",  and  Zuckerkandl ^l  These  observers  found 
partial  or  total  obliteration  of  the  appendix  with  increasing  age, 
while  obliteration  was  extremely  rare  in  children,  particularly  before 
the  fifth  year.  In  my  opinion  the  large  size  of  the  lumen  of  the 
appendix,  whereby  accumulations  of  secretions  and  pressure  necrosis 
are  prevented,  is  of  great  importance  in  explaining  the  rarity  of 
appendicitis  in  children. 

Besides  these  essential  factors  certain  predisposing  circum- 
stances play  an  undoubted  part.  Talamon  ^^  lays  stress  on  hered- 
ity. Some  families  present  a  predisposition  to  appendicitis.  Sahli 
also  mentions  such  cases.  Traumatism  is  mentioned  as  a  factor 
by  some  authors  (Coley  %  Small  ^,  Körte-Borchardt  ^*^,  and  others). 
Various  observers  give  chronic  constipation  as  a  predisposing 
cause.  In  209  appendicitis  cases  Fitz  ^'~'  found  constipation  only 
38  times. 

I  believe  we  must  differentiate  between  acute  and  chronic 
recurring  appendicitis.  According  to  my  experience  chronic  con- 
stipation is  quite  often  a  factor  in  the  latter,  but  much  less  so  in 
the  acute  form.  Treves  ^"^  regards  bad  teeth  and  insufficient  chew- 
ing of  food  as  frequent  causes  of  appendicitis.  Dyspeptic  con- 
ditions are  said  to  favour  this  disease.  In  English  literature  par- 
ticularly, rheumatism  and  gout  are  mentioned  as  predisposing  to 
an  attack. 

Recently  Golubeff  ^^  has  directed  attention  to  the  frequent  si- 
tnultaneous  occurrence  of  perityphlitis  in  Moscow,  and  has  therefore 
attributed  to  it  an  epidemic  character.  From  a  study  of  cases 
occurring  in  Erlangen  during  a  period  of  nine  years,  Penzoldt^ 
could  not  substantiate  this  conclusion.  At  times  I  have  seen  nu- 
merous simultaneous  perityphlitis  cases  in  Berlin  ;  a  number  of 
factors  may  here  have  acted  together. 

We  might  further  increase  the  list  of  accidental  causes  of  ap- 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  437 

pendicitis,  and  add  that  affections  of  the  female  genitals  also  pre- 
dispose to  appendicitis.  All  these  facts  can  not  overthrow  the  real 
practical  etiological  considerations  that  we  have  above  attempted  to 
establish. 

Perityphlitis  of  tuberciilous  or  actinomycotic  origin  presents  a 
certain  individuality.  The  former  not  infrequently  occurs  as  a 
latent  symptom  of  general  and  particularly  of  intestinal  tuberculo- 
sis. On  the  other  hand,  primary  tuberculous  disease  of  the  appendix 
with  a  characteristic  picture  of  appendicitis  is  exceptional.  From 
a  very  large  material  Sonnenburg  reports  but  3  cases  of  this 
kind.  Borchardt^^  also  reports  3  cases  occurring  in  Körte's  hos- 
pital service.  Karewski  ^^  has  operated  on  4  cases  in  children,  in 
2  of  which  he  thinks  the  disease  was  a  primary  isolated  tubercular 
appendicitis.  According  to  Borchardt,  tuberculosis  may  produce 
perityjDhlitic  abscesses  which  rupture  externally  and  cause  cfecal 
fistulse. 

Actinomycotic  appendicitis  is  more  infrequent.  In  his  mono- 
graph Sonnenburg  could  collect  only  12  cases  of  this  kind.  Karew- 
ski ^^  reports  a  further  case. 

In  conclusion,  we  wish  to  discuss  the  relative  frequency  of  this 
disease  in  the  various  periods  of  life  and  its  relation  to  sex. 

"We  have  already  dwelt  upon  the  relative  infrequency  of 
appendicitis  in  childhood.  Numerous  statistics  (Matterstock,  Fitz, 
ISTothnagel,  Sonnenburg)  demonstrate  that  the  second  and  third 
decades  of  life  present  a  very  striking  predisposition  to  appendi- 
citis. According  to  the  extensive  tables  of  Matterstock,  63  per 
cent  of  all  cases  of  appendicitis  occur  during  these  periods.  Ex- 
cept those  of  H.  Einhorn,  the  remaining  statistics  indicate  a  simi- 
lar conclusion. 

Regarding  the  relative  frequency  in  the  two  sexes,  according 
to  the  tabulations  of  Yolz,  Bamberger,  Matterstock,  Sonnenburg, 
Rotter,  ISTothnagel,  Fitz,  Pravaz,  and  Fen  wick,  appendicitis  is 
much  more  frequent  in  men  than  in  women,  while  others  (Ein- 
horn, Lennander,  and  Kiimmell)  could  discover  no  material  differ- 
ences in  frequency,  l^othnagel  correctly  points  to  the  greater 
frequency  of  appendicitis  in  the  male  even  in  childhood.  This 
is  also  evidenced  by  Matterstock's  extensive  tables  (51  male  chil- 
dren to  21  female). 


29 


438  DISEASES  OF  THE  INTESTINES 

Symptomatology  and  Diagnosis 

A.    Acute  and  Chronic  Typhlitis 

We  have  already  briefly  described  (page  432)  the  symptoms  of 
acute  typhlitis,  and  have  mentioned  pain  and  sensitiveness  to  pres- 
sure in  the  ceecal  region,  tympanites,  palpable  fsecal  accumulation, 
and  fever.  This  description  presupposes  a  simple  stercoraceous 
typhlitis.  We  have  as  yet  no  clear  clinical  picture  of  the  remain- 
ing forms  of  typhlitis,  at  least  not  of  the  acute  forms.  This  is  evi- 
dent fi'om  the  fact  that  in  almost  all  operations  in  which  typhlitis 
was  found  the  diagnosis  of  appendicitis  had  been  made.  It  is 
therefore  idle  to  lay  down  diagnostic  rules  and  j^rinciples  for  these 
other  forms  of  typhlitis.  But  in  the  present  state  of  our  knowl- 
edge even  the  differentiation  between  stercoraceous  typhlitis  and 
appendicitis  must  be  made  with  the  greatest  reserve.  Under  the 
following  circumstances  the  diagnosis  of  stercoraceous  typhlitis 
might  be  ventured.  Sudden,  obstinate  constipation,  moderate 
sensitiveness  over  the  c^cum,  mild  fever  or  none  at  all,  and 
absence  of  severe  general  symptoms.  The  intensity  of  the  sponta- 
neous pains  appears  to  me  irrelevant.  Objectively,  we  should  be 
able  to  palpate  a  faecal  tumour  characterized  by  its  compressibility 
and  perhaps  extending  high  up  along  the  ascending  colon.  There  is 
a  dull  percussion  note  over  the  tumour.  Chnical  course  :  Immediate 
disappearance  of  the  tumour  and  of  all  symptoms  after  a  laxative  or 
enema.  Only  in  the  presence  of  a  clinical  ensemble  as  well  marked 
as  this  can  the  diagnosis  of  [stercoraceous]  typhlitis  be  made  with  a 
fair  degree  of  probability.  So  typical  a  picture  is  certainly  not 
frequently  seen  in  practice,  because  the  majority  of  patients  have 
already  taken  laxatives  before  medical  advice  is  sought.  Even  in 
such  typical  instances  it  is  impossible  to  positively  differentiate  the 
affection  in  question  from  appendicitis  or  appendicular  colic.  We 
shall  recur  to  this  point  in  the  section  on  differential  diagnosis. 

Under  appropriate  circumstances  chronic  typhlitis  can  be  more 
easily  diagnosticated  than  the  acute  form.  The  absence  of  violent 
initial  symptoms,  the  very  slow  onset,  the  palpability  of  a  resist- 
ance in  the  caecal  region,  all  point  toward  the  diagnosis.  Since 
chronic  typhlitis  is  usually  tuberculous,  dysenteric,  or  carcinomatous 
in  character,  the  previous  history  or  other  clinical  phenomena  may 
give  important  diagnostic  data.  The  presence  of  stenotic  symptoms 
will  often  serve  to  make  the  etiology  positive.     As  proved  also  by 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  439 

surgical  experience,  it  is  very  difficult  to  diagnosticate  adhesions  about 
the  caecum  {perityphlitis  sensu  strictiori).  Even  admitting  the  very 
rare  instances  in  which  the  adhesions  can  plainly  be  felt,  it  will  be 
scarcely  possible  to  prove  their  origin  from  the  caecum.  At  most 
this  can  only  be  surmised. 

B.    Perityphlitis   (Appendicitis) 

1.  Acute  Perityphlitis 

In  many  instances  the  diagnosis  of  acute  perityphlitis  is  as  easy 
as  that  of  croupous  pneumonia  or  of  an  acute  monarthritis.  Con- 
versely, however,  the  clinical  picture  may  be  so  complicated  and 
atypical  that,  despite  great  experience  and  ability,  error  is  un- 
avoidable. The  statistics  of  Nothnagel,  already  given  (page  436), 
derived  from  the  very  extensive  material  of  the  Vienna  General 
Hospital,  contain  a  number  of  such  diagnostic  errors.  These  cases 
are  the  more  instructive  because  they  have  been  under  most  care- 
ful clinical  observation. 

The  diagnostic  difficulty  lies  in  another  direction.  Operations 
have  taught  us  the  numerous  and  various  changes  which  the  appen- 
dix may  undergo :  the  diseased  process  may  be  limited  to  the  mu- 
cous membrane,  or  to  the  peritoneal  coat,  or  may  affect  both ;  rup- 
ture may  take  place  into  a  preformed  encapsulated  space,  into  the 
general  peritoneal  cavity,  praeperitoneally,  retroperitoneal ly,  into  the 
intestines  or  other  hollow  viscera.  Even  during  laparotomy  it  may 
be  impossible  to  distinguish  these  various  forms  of  appendicitis. 
It  is  absolutely  necessary,  however,  to  understand  the  principal 
types,  and  to  be  able  to  recognise  the  most  important  clinical  com- 
plications of  the  disease. 

The  variations  in  the  clinical  picture  of  appendicitis  have  led  to  its 
classification.  Sonnen  burg  ^  was  the  first  to  establish  and  methodic- 
ally carry  out  such  clinical  divisions.    His  classification  is  as  follows  : 

1.  Simple,  catarrhal  appendicitis,  with  its  acute,  chronic,  ob- 
structive, and  cystic  forms. 

2.  Perforative  appendicitis :  («)  with  periappendicitis,  (J)  with 
general  peritonitis. 

3.  Gangrenous  appendicitis :  {a)  septic  peritonitis  without  per- 
foration, (b)  circumscribed  or  diffuse  peritonitis  accompanying 
beginning  perforation. 

Rotter^  has  divided  perityphlitis  more  simply  into  the  circum- 
scribed and  the  diffuse  forms.    Kümmeil  ^  divides  the  cases  into  the 


440  DISEASES  OP   THE   INTESTINES 

mild,  moderate,  and  severe — an  arrangement  whicli  is  followed  by 
Körte. 

ISTaturally  all  these  classifications  are  schematic,  and  give  only  an 
incomplete  idea  of  the  various  phases  and  clinical  courses  of  appendi- 
citis. Rotter's  arrangement  seems  to  me  the  simplest  and  least  pre- 
judicial, but  it  also  incompletely  represents  the  varieties  of  the 
disease.  With  much  hesitation,  we  shall  follow  Sonnenburg's 
nomenclature,  discarding  only  those  subdivisions  whicli  either  go 
too  far  or  not  far  enough. 

Though  such  differentiation  cannot  be  made  with  certainty,  we 
shall  also  distinguish  between  simple  perityphlitis  and  appendicular 
colic. 

(a)   Simple  Perityphlitis 

The  most  prominent  symptoms  are  sudden  onset ;  acute  pain  in 
the  ileo-csecal  region  ;  sensitiveness  to  pressure  in  the  region  of  the 
appendix,  and  eventually  of  the  tumour ;  gastric  disturbances ;  the 
condition  of  the  pulse  and  the  temperature. 

Each  of  these  symptoms  requires  detailed  consideration. 

1.  Sudden  Onset. — The  patients  are  usually  attacked  in  the 
midst  of  general  good  health.  Occasionally,  constipation  or  diar- 
rhoea precedes  the  attack.  The  attack  very  soon  becomes  so 
marked  that  the  patients  are  forced  to  take  to  bed. 

2.  Pain. — This  is  the  most  characteristic  symptom,  and  rap- 
idly reaches  its  greatest  intensity.  Adults  can  usually  localize 
the  pain  quite  well,  but  children  complain  of  general  stomach 
ache.  Some  patients  locate  the  greatest  area  of  pain  in  the  centre 
of  the  abdomen,  in  the  umbilical  or  epigastric  region.*  The  pain 
is  continuous,  and  shows  slight  or  no  remissions.  It  may  radiate 
to  the  right  thigh,  the  back,  the  testicle,  or  the  bladder.  In  the  last 
instance  bladder  symptoms  may  be  present,  and  there  may  even  be 
retention  of  urine.  The  respiration  is  a  useful  gauge  for  the  intensity 
of  the  pain.  In  well-marked  cases  the  breathing  is  rapid,  superfi- 
cial, and  costal ;  the  patients  anxiously  avoid  deep  inspiration.  The 
patient  feels  most  comfortable  when  lying  quietly  on  his  back  ;  every 
movement  increases  his  pain,  absolute  rest  decreases  it. 

3.  Sensitiveness. — Sensitiveness  to  pressure  over  McBurney's 
point  is  the  most  valuable  and  reliable  of  the  objective  symptoms. 
The  sensitiveness  varies  in  intensity,  but  in  the  beginning  is  fairly 

*  [Hartley"  states  that  only  in  one  fourth  of  the  cases  is  the  initial  pain  referred 
to  the  right  iliac  fossa. — Tr.] 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  441 

well  localized.  As  Fowler^*  points  oat,  there  is  a  certain  amount 
of  rigidity  on  palpation  of  the  right  rectus  muscle.  He  also  calls 
attention  to  an  interference  with  the  function  of  the  abdominal 
respiratory  muscles,  evidently  caused  by  the  above-mentioned 
superficial  and  rapid  breathing,  Regarding  the  possibility  of 
palpating  the  inflamed  appendix,  to  which  Edebolils  ^^  in  partic- 
ular refers,  views  diifer.  Sonnenburg,  whose  opinion  is  certainly  of 
great  value,  says  "  that  the  thickened  appendix  cannot  be  palpated 
during  acute  attacks,  but  may  be  jDalpable  in  the  intervals." 
Fowler  ^  speaks  of  "  exceptional  identification  in  cases  of  chronic 
appendicitis." 

Admitting  the  possibility  of  feeling  the  appendix,  this  fact  is 
on  the  whole  of  small  practical  significance.  A  circumscribed  pain- 
ful area  in  the  ileo-csecal  region  is  a  sufiicient  clinical  symptom. 

4.  Perityphlitic  Tumour. —  Under  appropriate  treatment  the 
sensitiveness  may  disappear  in  a  short  time,  or  may  increase  with 
the  onset  of  high  fever  and  the  development  of  a  perityphlitic 
tumour.  Of  what  does  this  tumour  consist  ?  According  to  Sahli  \ 
it  is  mainly  composed  of  a  thickening  of  the  intestinal  wall,  the  vis- 
ceral and  parietal  layers  of  the  peritoneum,  and  the  fascia  trans- 
versalis  of  the  abdominal  muscles;  in  addition,  there  are  fibrous 
adhesions  of  the  intestines,  not  infrequently  thickening  of  the 
omentum,  and  stagnation  of  the  intestinal  contents. 

In  general,  even  small  tumours  of  the  iliac  fossa  are  readily 
palpable.  In  perityphlitis,  because  of  the  rapid  onset  of  intestinal 
paralysis,  the  intestines  become  distended  with  gases  and  the  tumour 
is  thereby  brought  nearer  to  the  surface.  The  tumour  is  felt  either 
as  a  circumscribed,  easily  defined  mass,  or  as  a  diffuse,  doughy 
swelling  (Roux).  In  other  cases,  especially  when  there  is  marked 
meteorism,  or  when  the  appendix  is  situated  behind  the  caecum, 
recognition  of  the  tumour  by  palpation  is  difficult.  In  all  these 
cases  rectal  or  vaginal  examination  is  of  great  value,  especially 
since  the  appendix  is  sometimes  situated  low  down  in  the  small 
pelvis  and  may  there  give  rise  to  abscesses. 

In  doubtful  cases  exploratory  puncture  may  render  important 
diagnostic  aid.  At  present  the  views  regarding  the  value  of  this 
procedure  are  contradictory.  Some  prominent  surgeons  (Sonnen- 
burg, Roux,  Karewski,  Fowler,  and  Treves)  have  entirely  given  up 
puncture,  while  Körte,  Borchardt,  Lauenstein,  as  well  as  the  major- 
ity of  internal  practitioners  (v.  Leyden,  A.  Fraenkel,  Fürbringer, 
Renvers,    Curschmann,    Sahli,    Nothnagel,  Penzoldt,  and    others), 


442  DISEASES   OF  THE  INTESTINES 

strongly  recommend  it.*  Summing  up  the  experience  of  the  latter, 
we  may  say  that  exploratory  puncture  is  usually  not  a  dangerous 
procedure.  Puncture  of  the  intestines  cannot  always  be  avoided. 
Penzoldtf  believes  he  has  occasionally  punctured  the  bowel  with- 
out causing  any  trouble.  Karewski  saw  two  injuries  of  the  intes- 
tines from  puncture  during  operation,  which,  he  states,  were  not 
followed  by  deleterious  effects.  In  another  case  Karewski  ascribes 
a  peritonitis  (and  subsequent  operation)  to  puncture,  but  I  am  not 
convinced  of  the  correctness  of  his  statements. 

In  my  opinion,  we  should  puncture  only  when  an  abscess  is  sus- 
pected and  its  presence  cannot  otherwise  be  determined.  I  do 
not  consider  it  advisable  to  employ  exploratory  puncture  for  the 
purpose  of  showing  the  patient  the  necessity  of  an  operation,  for 
the  patient  may  recover  without  operation — a  fact  which  would 
place  the  physician  in  a  rather  awkward  predicament. 

Regarding  exploratory  puncture,  Penzoldt^*'  has  laid  down  sev- 
eral excellent  rules,  which  we  here  reproduce. 

The  needle  must  have  as  large  a  lumen  as  possible  and  still  be  fine,  long, 
and  strong  enough  to  withstand  bending.  Instead  of  the  point  having  the 
usual  lancet-shaped  tip  and  being  sharpened  laterally,  it  should  be  round  and 
only  sharpened  at  its  extreme  tip,  so  that  the  lower  end  of  the  needle  is  not 
larger  than  the  upper,  thus  avoiding  an  unnecessarily  large  puncture. 

If  carbolic  acid,  or  ether  and  alcohol,  have  been  used  to  disinfect  the  nee- 
dle, sterilized  water  should  be  drawn  through  the  needle  directly  before  punc- 
ture, because  any  portion  of  the  above  disinfectants  remaining  in  the  syringe 
may  precipitate  the  albumin  of  the  fluid  aspirated  and  thereby  give  rise  to 
difficulties.  (For  the  better  conservation  of  the  cell  elements,  I  draw  sterilized 
salt  solution  through  the  syringe  directly  before  and  after  aspirating.)  The 
needle  must  fit  the  barrel  of  the  syringe  well.  The  puncture  is  made  at  the 
point  of  greatest  resistance  and  dulness ;  if  necessary,  several  punctures  may  be 
made.  After  puncture  of  the  abdominal  muscles,  the  piston  is  slightly  with- 
drawn ;  if  nothing  be  aspirated,  the  needle  is  pushed  in  somewliat  deeper,  the 
piston  being  retained  in  the  same  position.  The  piston  is  then  drawn  out 
somewhat  further,  and  if  again  nothing  be  aspirated,  the  needle  is  thrust 
deeper,  the  piston  then  further  withdrawn,  and  so  on  till  the  piston  has  been 
drawn  out  its  entire  length.  The  syringe  should  be  large  enough  to  hold 
3  to  3  cubic  centimetres,  so  that  a  large  area  may  be  explored  through  one 
puncture.  The  needle  is  steadied  slightly  with  the  left  hand,  so  that  it  may 
follow  the  movements  of  the  abdominal  muscles.  Puncture  must  never  be 
performed  without  a  microscope  near  at  hand,  so  that  clear  fluid  may  be  imme- 

*  [Exploratory  puncture  is  a  procedure  not  generally  practised  in  the  United 
States ;  it  is  rare  to  find  it  mentioned  in  text-books  and  monographs,  and  when 
mentioned  it  is  usually  condemned. — Tr.] 

t  Loc.  cit.,  p.  671.    ' 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  443 

diately  exnmined  for  cellular  elements.  The  small  amount  of  fluid  hidden 
in  the  needle  may  be  easily  identified.  ("Where,  as  in  private  practice,  especially 
in  the  country,  a  microscope  is  not  handy,  it  is  better  to  send  the  entire  syringe 
in  a  properly  stoppered  container  for  examination.) 

Compared  with  the  above  diagnostic  data,  percussion  is  of  sec- 
ondary importance.  It  is  clear  that  in  the  presence  of  a  distinct 
exudate  the  percussion  is  dull  or  dull  tympanitic  ;  but  if  the  exudate 
be  situated  very  deeply,  percussion  will  scarcely  be  of  diagnostic  aid. 

The  same  is  also  true  of  auscultation.  For  the  purpose  of  differ- 
entiation between  simple  and  septic  paralysis  of  the  intestinal  mus- 
cles, Richardson  ^  states  that  intestinal  sounds  are  present  in  th6  for- 
mer and  absent  in  the  latter.  'The  "rumbling"  sound  described  by 
Naumann  ^^  as  characteristic  of  abscess  does  not  appear  to  have  been 
observed  by  others.  In  a  case  without  suppuration  Borchardt  *  dis- 
covered this  sound,  which  he  considers  an  ordinary  intestinal  noise. 

5.  Gastric  Disturiances. — These  consist  in  loss  of  appetite  and 
occasionally  of  vomiting,  especially  in  the  beginning.  In  children 
vomiting  is  often  the  ushering-in  symptom,  and  may  be  productive 
of  diagnostic  errors — e.  g.,  acute  dyspepsia,  intestinal  catarrh,  etc. 
In  the  further  course  of  the  disease  the  vomiting  generally  ceases, 
but  should  it  persist  and  become  more  marked,  suspicion  of  severe 
invasion  of  the  peritoneum  must  immediately  be  aroused.  Should 
the  vomiting  become  fgecal  in  character,  we  must  think  of  the 
possibility  of  mechanical  or  j)aralytic  intestinal  obstruction  accom- 
panied by  peritonitis. 

6,  Temper  attire. — Temperature  is  of  great  diagnostic  and  prog- 
nostic importance.  In  simple  catarrhal  appendicitis  the  tempera- 
ture is  low  and  falls  raj^idly,  but  in  the  purulent  and  perforative 
forms  it  very  soon  becomes  quite  high,  and  remains  so  for  a  longer 
or  shorter  time.  To  avoid  repetition,  we  shall  now  discuss  the 
course  of  the  temperature  in  all  the  different  varieties  and  stages  of 
appendicitis.  Rotter  ^^  has  made  a  careful  study  of  the  temperature 
in  the  various  forms  of  appendicitis,  and  although,  as  must  be  ex- 
pected from  its  protean  type,  the  disease  contradicts  all  rules  and 
experience,  the  fever  curves  of  Rotter  are  very  important  for  the 
recognition  of  the  status  of  individual  cases.  Rotter  arranges  the 
cases,  according  to  their  temperature,  into  five  groups : 

The  first  group  is  ushered  in  by  marked  fever  (up  to  40°  C.  and 
over),  with  or  without  a  chill ;  after  3  or  4  days  there  is  a  tend- 

*  Loc.  cit.,  p.  330. 


444  DISEASES  OP   THE   INTESTINES 

ency  to  defervescence.  These  cases  are  characterized  by  a  smooth 
and  rapid  convalescence. 

In  the  beginning  cases  of  the  second  group  are  not  distinguish- 
able from  those  of  the  first.  The  fever,  however,  lasts  longer ; 
after  the  fifth  day  the  temperature  is  not  higher  than  39°  C.  These 
cases  also  recover,  though  sometimes  only  after  operation. 

The  third  group  is  characterized  by  the  fact  that  after  the  fifth 
day  the  temperature  remains  above  39°  C.  From  the  time  of  onset 
these  cases  present  more  or  less  high  fever,  and  also  slight  remis- 
sions followed  by  increase  of  temperature.  Most  of  these  cases 
generally  run  a  severe  course  and  sooner  or  later  require  operation ; 
of  those  not  operated  upon  some  recover  and  others  die. 

The  fourth  groiip  includes  those  which  present  a  remittent  type  of 
fever.  The  initial  fever  is  followed  by  defervescence,  but  after  a  few 
days  the  temperature  again  rises.  This  second  rise  indicates  suppura- 
tion. Most  of  these  cases  required  operation.  Of  those  not  operated 
upon,  one  seemingly  recovered,  another  died  of  diffuse  peritonitis. 

In  the  fifth  group,  which  includes  those  with  diffuse  peritonitis, 
temperature  has  no  special  significance.  It  may  be  high,  normal, 
or  even  subnormal.  If  a  circumscribed  abscess  ruptures  into  the 
general  abdominal  cavity,  there  is  a  sudden  fall  of  temperature, 
often  subnormal  and  accompanied  by  collapse. 

Y.  Pulse. — ISText  to  temperature,  the  frequency  of  the  pulse 
and  its  possible  irregularity  are  of  the  greatest  value.  There  is  a 
special  significance  in  a  disproportion  between  temperature  and 
pulse.  From  numerous  operations  we  know  that  severe  peritonitis 
may  exist  without  any  rise  of  temperature.  It  is  in  these  cases,  of 
which  I  have  observed  several,  that  the  character  of  the  pulse 
becomes  the  only  diagnostic  and  prognostic  indication.*  On  the 
other  hand,  Lennander,t  Karewski^^,  and  others,  have  shown 
that  in  the  severest  cases  of  progressive,  suppurative,  fibrinous 
peritonitis,  both  temperature  and  pulse  may  be  almost  normal 
(Mikulicz).  A  distinct  and  continuously  irregular,  and  at  the  same 
time  very  small  pulse,  is  almost  always  an  ominous  sign. 

Finally,  we  would  mention  an  interesting  phenomenon  pointed 
out  by  Mannaberg  ^,  viz.,  the  accentuation  of  the  second  pulmonary 
sound.  He  discovered  this  symptom  in  cases  of  perityphlitis 
offener  than  could  be  accounted  for  by  mere  accident. 

*  [In  the  United  States  the  pulse  is  generally  regarded  as  the  most  valuable 
single  prognostic  and  therapeutic  indicator  in  appendicitis. — Tr.] 
t  Loc.  cit.,  p.  27. 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  445 

(b)  Appendicular  Colic 

Under  the  name  of  colique  apijendiculaire  Talamon  *  first  de- 
scribed a  clinical  picture  characterized  bj  the  following  symptoms  : 
The  patient  is  suddenly  attacked  by  very  severe  pains,  occasionally 
accompanied  by  vomiting.  The  region  of  the  appendix  is  extremely 
sensitive  to  pressure  ;  fever  is  either  very  moderate  or  entirely  ab- 
sent ;  a  tumour  never  forms.  The  attack  passes  off  very  rapidly. 
Spontaneously,  or  after  morphin,  the  patients  are  absolutely  well  at 
the  end  of  twenty-four  to  thirty-six  hours.  Talamon  explains  this 
condition  by  supposing  that  a  fgecal  concretion  is  wedged  into  the 
appendix  and  thereby  causes  violent  muscular  contractions ;  finally 
the  concretion  falls  back  into  the  csecum,  similar  to  a  gall-stone  fall- 
ing back  into  the  gall  bladder  after  having  reached  the  cystic  duct. 

Yon  Hochstätter^^,  Caspersohn  *',  Goldbach  *i,  Treves  1^,  :N'oth- 
nagel,  Sonnenburg,  and  A.  Pick^  have  described  such  cases.  I 
have  seen  a  large  number  of  these  cases,  but  in  view  of  the  sim- 
plicity of  the  clinical  picture  I  shall  not  describe  any.  In  my 
experience  the  patients  are  generally  individuals  who  suffer  fre- 
quently from  such  attacks  (every  four  to  six  weeks  or  offener).  In 
the  interval  they  are  absolutely  well,  but  the  attacks  may  finally  be- 
come continuous,  and  assume  the  character  of  chronic  perityphlitis. 

All  authorities  agree  upon  the  symptoms,  but  there  is  a  diver- 
sity of  opinion  regarding  the  origin  of  this  disease.  Treves" 
denies  the  possibility  of  muscular  contraction  of  a  healthy,  let 
alone  a  diseased,  appendix,  and  characterizes  this  theory  as  "  wholly 
ridiculous."  ü^othnagel  admits  the  possibility  of  spasmodic  con- 
traction, but  does  not  consider  it  proved  that  coproliths  wedge 
themselves  into  the  appendix.  Monod  and  Yanvers^^  express  a 
somewhat  similar  opinion.  Opposed  to  these  theories  is  the  cited 
case  of  Goldbach,  observed  in  Wölfler's  clinic  in  Prague. 

The  patient  was  a  sixteen-year-old  scholar,  who  for  one  j'ear  had  suffered 
from  jaundice  and  severe  colicky  pains  under  the  right  free  border  of  the  ribs. 
He  never  had  fever  or  vomiting  during  the  attack.  Always  had  obstinate  con- 
stipation. Later,  pains  were  present  in  the  evening  and  absent  in  the  morning 
He  now  has  pain  in  the  ileo  caecal  region,  localized  directly  over  McBurney's 
point.  No  concretion  was  ever  found  in  the  stools.  Palpation  shows  an  oval, 
fairly  soft  tumour  (caecum  ?),  over  which  may  plainly  be  felt  a  second  longi- 
tudinal sausage-shaped  tumour.  The  entire  mass  appears  movable,  and  is  felt 
either  in  the  right  hypochondrium  or  in  the  lower  abdominal  region.     Liver 

*  Talamon,  Appendicite  et   Perityphlite,   Paris,  1892,  p.  25   et  111;    Colique 
appendiculaire  medecine  moderne,  1890,  p.  837. 


446  DISEASES   OF   THE   INTESTINES 

is  not  enlarged.  At  the  operation  two  small  fgecal  stones  were  found  in  the 
caecum.  When  these  were  pressed  toward  the  appendix  they  easily  slipped  in, 
and  could  just  as  easily  be  forced  back  into  the  csecum.  The  appendix  was 
absolutely  normal.     Extirpation  of  the  appendix.     Cure. 

This  case  at  least  proves  the  possibility  of  foreign  bodies  slip- 
ping into  the  appendix  and  again  falling  back  into  the  csecum.  It 
is  very  questionable  whether  this  is  a  constant  or  only  frequent  oc- 
currence. From  the  fact  that  in  most  autopsies  [and  operations] 
for  recurring  appendicitis  (which  the  above  case  greatly  resembles) 
slight  changes  are  found  in  the  appendix,  it  would  seem  that  these 
are  after  all  very  mild  forms  of  simple  catarrhal  appendicitis. 

(c)  Perforative  Perityphlitis 

Pathological  anatomy  and  the  results  of  operation  agree  that 
perforations  occur  very  frequently  in  appendicitis.  It  is  therefore 
important  to  be  able  to  diagnosticate  this  complication.  Sonnen- 
burg gives  certain  symptoms  as  characteristic  :  Violent  onset  with 
high  fever ;  severe  abdominal  pain  beginning  suddenly  or  imme- 
diately after  a  meal,  and  very  soon  localized  on  the  right  side  ; 
vomiting,  accompanied  by  diarrhoea  or  constipation ;  small,  fre- 
quent pulse  ;  fever,  rising  rapidly  and  often  ushered  in  by  a  chill ; 
marked  tympanites.  Patient  feels  extremely  ill.  There  is  slight 
cyanosis  and  persj)iration.  Distinct  resistance  in  the  vicinity  of 
the  suppurative  area. 

The  diagnosis  of  perforation,  however,  cannot  be  positively 
made  from  any  of  these  symptoms,  for  suppurative  appendicitis  with 
tumour,  severe  general  disturbance,  high  temperature,  and  rapid 
pulse  may  give  a  very  similar  picture.* 

It  will  therefore  be  wiser  not  to  attempt  to  make  the  diag- 
nosis of  perforative  peritonitis,  but  to  content  ourselves  with  the 
diagnosis  of  suppurative  appendicitis. 

(d)  Diffuse  Suppurative  Perityphlitis 

According  to  Rotter,  diffuse  suppurative  perityphlitis  originates 
in  two  ways  :  either  as  a  purulent  perityphlitis,  in  which  the  adhe- 
sions between  the  intestinal  coils  continue  to  extend,-  or  by  per- 
foration of  a  previously  encapsulated  abscess,  whose  contents  spread 
over  the  general  abdominal  cavity.  In  both  cases  the  pus  generally 
gravitates  toward  the  lower  right  side  of  the  pelvis  and  Douglas's 

*  [A  blood  count  might  prove  of  great  value  in  differentiating  the  two  condi- 
tions.   Marked  leucoeytosis  would  speak  for  suppurating  appendicitis. — Tr.] 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  447 

cul-de-sac  ;  if  the  process  continue,  the  pus  spreads  to  the  left  side 
of  the  pelvis,  and  from  there  over  the  different  abdominal  organs. 

The  diagnosis  of  the  various  phases  of  this  variety  may  be 
extremely  difficult.  Temperature,  pulse,  and  objective  symptoms 
may  be  deceptive,  and  easily  lead  to  false  conclusions.  As  al- 
I'eady  remarked,  if  high  temperature  is  present,  it  is  irregular  and 
remittent  in  character,  becoming  normal,  again  suddenly  rising,  etc. 
The  most  reliable  symptom  is  the  general  appearance.  The  pa- 
tients are  usually  markedly  collapsed,  depressed,  apathetic,  the  fea- 
tures are  pinched  and  sunken,  and  are  pale,  cyanotic,  and  without 
congestion ;  the  eyes  are  staring ;  there  is  absolute  sleeplessness  and 
anorexia ;  the  tongue  is  dry  and  cracked ;  occasionally  there  is 
singultus.  In  a  word,  the  patient  makes  a  septic  impression. 
To  this  picture  there  are  excöptions.  The  patient  may  feel  well, 
sit  up  in  bed,  his  pulse  and  temperature  be  properly  proportioned 
and  not  high,  and  yet  laparotomy  will  reveal  a  diffuse,  septic  perito- 
nitis. In  other  cases,  very  grave  symptoms  are  at  first  present ; 
then  suddenly  the  patient  becomes  better,  "the  suppuration  be- 
comes circumscribed"  (Rotter).  Contrary  to  expectation,  the  pa- 
tient recovers,  perhaps  only  after  one  or  several  abscesses  have  been 
opened.  ]S[umerous  other  varieties  are  seen  in  practice,  but  a 
schematic  description  is  impracticable,  because  every  case  presents 
special  peculiarities.  We  have  here  purposely  given  the  clinical 
picture,  but  not  the  diagnostic  criteria  of  diffuse  perityphlitis,  be- 
cause after  all  the  general  impression  created  by  the  patient  is  the 
decisive  diagnostic  factor. 

The  diagnosis,  and  I  may  add  the  prognosis,  often  vary  ex- 
tremely, as  the  clinical  picture  changes  from  day  to  day.  This 
should  warn  us  never  to  give  a  prognosis  too  early  in  the  dis- 
ease. 

2.   Chronic  Perityphlitis 

Chronic  or  recurring  perityphlitis  is  that  form  in  which,  after  a 
longer  or  shorter  interval,  renewed  attacks  of  the  disease  occur. 
The  American  surgeons  (Bull^^,  Fowler  %  and  others)  designate 
this  form  as  "  recurring  "  appendicitis,  and  distinguish  it  from  those 
cases  in  which  the  acute  attack  is  recovered  from,  but  a  sensitive- 
ness to  touch  persists  in  the  ileo-csecal  region.  The  last  form  has 
been  called  "relapsing"  appendicitis,  though  some,  like  Fenger 
of  Chicago,  call  it  "  postappendicitis." 

The  studies  of  surgeons,  particularly   Sonnenburg,  Kümmell, 


448  DISEASES  OF  THE  INTESTINES 

Bull,  Fowler,  Körte,  Treves,  and  Senn,  have  given  us  valuable  in- 
formation regarding  clironic  appendicitis.  Tliis  disease  may  develop 
in  many  different  ways.  The  most  frequent  mode  is  through  the 
formation  of  partial  obliterations  (appendicitis  obliterans,  Senn)  and 
strictures,  with  consequent  stagnation  of  secretion,  formation  of  cysts, 
and  occasionally  of  empyema  of  the  appendix.  More  or  less  exten- 
sive adhesions  may  develop  about  the  appendix,  and  cause  functional 
irregularities  of  the  intestine,  bladder,  and  female  genitals,  and  pro- 
duce pain  and  other  disturbances.  The  mucous  membrane  of  the  ap- 
pendix may  be  diseased,  and  small  swellings  and  suppurations  exist  in 
or  around  the  appendix ;  fsecal  concretions  are  sometimes  present. 
Under  such  conditions  the  appendix  may  perforate  during  a  relapse. 

If  we  limit  ourselves  to  the  diagnosis  of  a  diseased  process  in  or 
about  the  appendix,  we  will  scarcely  ever  meet  with  any  difficulty. 
The  history  may  give  us  valuable  information.  More  important, 
however,  are  the  typical  symptoms  (pain,  even  while  at  rest,  but  in- 
creased by  motion  or  straining ;  constipation)  and  the  discovery  of 
a  circumscribed  area  of  sensitiveness  to  pressure,  and  of  infiltrations 
about  the  ciECum  or  appendix. 

In  recurrent  perityphlitis  the  patients  have  no  symptoms  be- 
tween the  attacks.  From  time  to  time,  either  without  recognisable 
cause  or  after  strains,  errors  in  diet,  colds,  or  constipation,  the 
pain  recurs,  a  palpable  tumour  in  the  appendix  region,  accompanied 
by  fever,  nausea,  and  vomiting,  appears,  and  in  about  one  half  the 
eases  perforation  occurs. 

As  Treves  has  pointed  out,  and  as  is  generally  known,  the  recur- 
ring attacks  are  usually  not  as  severe  as  the  primary  one.  In  recur- 
ring SiTp-pendidtis  perityphlitio  abscesses  seem  to  develop  very  rarely. 
Talamon  *  records  a  case  in  which  an  abscess,  necessitating  surgical 
treatment,  developed  in  each  of  four  attacks. 

In  the  vast  majority  of  instances  the  proper  diagnosis  can  be 
made  from  the  symptoms  above  enumerated.  The  diagnosis  is 
difiicult  only  in  those  cases  in  which  appendicitis  must  be  distin- 
guished from  disease  of  the  female  genitals.  We  shall  discuss  this 
under  differential  diagnosis.  On  the  other  hand,  it  is  almost  impos- 
sible to  diagnosticate  the  individual  pathological  conditions  in  and 
about  the  appendix ;  it  would  therefore  be  useless  to  enter  into  a 
discussion  of  the  diagnosis  of  this  point,  which,  moreover,  is  of 
little  practical  value. 

*  Loc.  cit.,  p.  151. 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  449 

Differential  Diagnosis 

The  diagnosis  of  a  typical  case  of  appendicitis  is  simple ;  it  may 
become  quite  difficult  when  the  disease  runs  an  irregular  course,  or 
when  the  patient  is  first  seen  during  the  late  stages  of  the  disease. 
It  is  impossible  to  consider  all  the  numerous  differentia]  possibili- 
ties ;  in  the  following  we  shall  discuss  only  the  important  ones. 

Simple  appendicitis  gives  rise  to  the  least  difficulty.  Mis- 
takes may  occur  if  the  pain  is  atypically  localized,  or  if  the  objec- 
tive symptoms  are  entirely  or  almost  entirely  absent. 

In  the  former  instance  (i.  e.,  the  atypical  location  of  the  pain) 
we  must  consider  biliary  and  renal  colic,  and  occasionally  mucous 
colic.  In  most  cases  careful  observation  will  scarcely  leave  room 
for  doubt.  According  to  ITaunyn,  the  examination  of  the  urine 
for  indican  may  be  of  value.  I^aunyn^^  states  that  indican  is 
never  absent  in  appendicitis,  while  in  biliary  colic  it  is  only  occa- 
sionally present.  As  another  important  diagnostic  fact,  it  must  be 
mentioned  that  in  cholelithiasis  the  posterior  surface  of  the  liver, 
between  the  tenth  and  twelfth  dorsal  vertebrae,  two  to  three  finger- 
breadths  to  the  right  of  the  vertebral  column,  is  sensitive  to  pressure. 
In  nephrolithiasis,  it  will  be  necessary  to  carefully  palpate  the  riglit 
kidney  and  to  examine  the  urine. 

In  children,  and  sometimes  in  adults,  appendicitis  may  be  con- 
founded with  "  febrile  gastro-enteritis."  Karewski  ^^,  in  particular, 
has  directed  attention  to  these  errors,  and  every  physician  will 
appreciate  his  warning.  If,  as  a  result  of  this  error,  these  cases 
are  treated  with  calomel  and  castor  oil,  serious  danger  may  arise. 
In  children,  in  all  cases  of  so-called  febrile  gastro-enteritis  accom- 
panied by  acute  pain,  we  should  at  once  think  of  appendicitis.  If 
we  then  err,  there  can  never  occur  the  severe  consequences  that 
may  otherwise  arise. 

The  diagnosis  is  far  more  difficult  if  the  sensitiveness  to  pressure 
or  an  exudate  is  localized,  not  at  McBurney's  point,  but  at  other 
places — e.  g.,  in  the  right  or  left  hypochondrium,  the  umbilical 
region,  the  left  iliac  fossa,  etc. 

The  experiences  of  surgeons,  particularly  the  oft-quoted  topo-  - 
graphical  clinical  studies  of  Curschmann,  have  shown  us  how  the 
caecum  and  the  appendix  may  be  found  in  various  situations.  In 
one  case,  close  to  the  right  costal  border,  Curschmann  ^"^  found  a 
hard  superficial  tumour  the  size  of  the  palm  of  the  hand.  The 
tumour  lay  in  front  of  the  intestines,  and  was  connected  with  the 


450  DISEASES  OF  THE  INTESTINES 

inner  surface  of  the  abdominal  wall.  Judging  from  its  origin,  posi- 
tion, and  form,  it  was  a  peritonitic  exudate.  The  patient  died  of 
general  peritonitis.  At  the  autopsy  the  caecum  was  found  turned 
up  in  front  of  the  descending  colon,  with  the  appendix  touching  the 
Uver(see  Fig.  25). 

I  herewith  present  a  similar  case  described  by  Rotter : 

A  man,  fifty-one  years  old,  while  under  ambulatory  treatment  at  Kissingen, 
became  ill  with  gangrenous  appendicitis.  Eight  days  after  the  onset  of  the 
disease  a  tumour  was  found  between  the  liver  and  the  ascending  colon.  The 
most  striking  feature  was  the  great  mobility  of  the  tumour;  it  could  easily  be 
moved  across  the  middle  line  toward  the  left,  whereas  perityphlitic  tumours  in 
general  are  diffuse,  and  attached  to  the  posterior  abdominal  wall. 

The  diagnosis  rested  between  a  tumour  of  the  colon  and  of  the 
kidney  till  an  exploratory  puncture  showed  feculent  pns.  The  great 
mobility  of  the  tumour  was  due  to  the  fact  that  it  was  not  adherent 
to  the  anterior  or  posterior  abdominal  wall,  bat  rested  upon  the  right 
side  of  the  mesentery  of  the  small  intestine,  the  remainder  of  the 
abscess  wall  being  formed  by  coils  of  adherent  intestine.  In  dis- 
placing the  tumour,  the  mesentery  and  adherent  bowel  moved 
with  it. 

In  his  Clinic  of  Cholelithiasis,  JSTaunyn  mentions  similar  in- 
stances. Almost  all  experienced  surgeons  (particularly  Sonnenburg, 
Lennander,  Fowler,  Körte,  and  Riedel)  have  reported  similar  cases. 
The  practical  conclusion  to  be  drawn  is  that,  although  an  exudate  or 
localized  sensitiveness  be  found  in  other  than  in  the  typical  situa- 
tion, we  must  always  keep  in  mind  the  possibility  of  appendicitis. 

Cases  of  pericolitis  and  sigmoiditis  (later  to  be  described)  show 
that  inflammatory  exudates,  though  indeed  more  rarely,  may  occa- 
sionally originate  from  other  sources  than  the  appendix. 

Exploratory  puncture  may  be  of  diagnostic  value.  The  with- 
drawal of  feculent  pus  indicates  a  perforating  appendicitis. 

It  may  be  very  difficult  to  differentiate  between  inßammatory 
disease  of  the  female  adnexa  and  appendicitis.  The  differentiation 
may  be  impossible  when,  as  often  happens,  appendix  and  adnexa  are 
simultaneously  diseased.  I  have  seen  several  cases  of  this  kind. 
Accumulations  of  pus  in  Douglas's  pouch  may  also  give  rise  to  diag- 
nostic errors.  Borchardt  thinks  that  the  differentiation  can  be  made 
by  examining  the  pus  for  bacterium  coli  communis,  the  presence  of 
which  would  speak  for  appendicitis. 

For  further  details  of  the  subject  the  reader  is  referred  to  the 
monograph  of  Sonnenburg. 


TYPHLITIS,  PERITYPHLITIS  (APPENDICITIS)  45 1 

The  differential  diagnosis  is  quite  difficult  where  the  appendix  is 
in  the  small  pelvis  and  there  gives  rise  to  an  abscess.  In  these  in- 
stances the  differential  diagnosis  between  appendicitis  and  inflamma- 
tory disease  of  the  adnexa  can  rarely  be  made. 

Tumours,  particularly  of  the  csecum,  may  be  mistaken  for 
chronic  appendicitis,  and,  much  more  infrequently,  for  acute  appen- 
dicitis. The  tumours  here  to  be  considered  are  sarcoma,  carcinoma, 
actinomycosis,  tubercular  tumours  of  the  caecum,  occasionally  also 
ileo-c88cal  invagination. 

For  purposes  of  differentiation,  Sonnenburg  ^''  recommends  infla- 
tion of  the  intestines.  In  perityphlitic  exudates  the  intestines  be- 
come distended,  in  neoplasms  they  remain  rigid.  The  mobility  of 
a  questionable  tumour  speaks  decidedly  against  an  exudate ;  but 
immobility  does  not  speak  against  neoplasms,  since  they  may  be 
fixed  by  adhesions.  Where  symptoms  of  stenosis  of  the  large 
bowel  are  present  the  diagnosis  may  be  easy.  If  these  be  absent, 
the  insidious  course,  the  cachexia  (in  malignant  tumours),  the  pres- 
ence of  blood  or  pus  in  the  stools,  will  indicate  the  correct  condi- 
tion. Reports  of  cases  show,  however,  that  numerous  errors  are 
made  which  are  only  cleared  up  by  operation  or  autopsy.  (Com- 
pare with  chapter  on  Intestinal  Carcinoma.) 

Finally,  we  have  the  rare  occurrence  of  the  inflamed  appendix  in 
a  hernial  sac  (inguinal  or  femoral  canal)  which  has  resulted  from 
foetal  maldevelopment.  This  may  occur  on  the  left  as  well  as  on 
the  right  side.  These  cases  run  their  course  as  incarcerated  her- 
nise,  and  are  of  great  surgical  interest.  The  diagnosis  is  9,lmost  im- 
possible. 

Appendicitis  in  the  stage  of  diffuse  peritonitis  may  cause  con- 
siderable diagnostic  difficulty.  This  originates  under  very  differ- 
ent circumstances.  In  the  first  place,  diagnostic  confusion  may  be 
present  when,  in  the  midst  of  apparently  normal  health,  or  after 
obscure  premonitory  symptoms,  signs  of  perforative  peritonitis 
appear.  It  is  difficult  to  determine  the  cause  of  the  condition  and 
the  proper  site  for  the  surgical  incision,  upon  which  considerations 
the  life  of  the  patient  may  depend.  In  the  chapter  on  Duodenal 
Ulcer  (page  293)  we  have  seen  that  not  infrequently  a  perforation 
of  the  appendix  is  sought  for,  and  autopsy  reveals  a  perforating 
duodenal  ulcer. 

Regarding  the  differentiation  between  perforations  of  duodenal 
or  gastric  ulcers  and  perityphlitic  abscesses,  Marmaduke  Sheild"*^ 
ascribes  great  value  to  the  fsecal  smell  of  the  pus  and  the  gas  bub- 


453  DISEASES   OF  THE  INTESTINES 

bles  formed  ;  these  would  indicate  disease  of  the  appendix  and 
caecum.  He  also  lays  stress  upon  the  reaction  of  the  pus,  which  is 
neutral  or  alkaline  in  appendicitis,  and  acid  in  the  others.  Mistakes 
like  the  above  will  never  be  unavoidable,  but  they  warn  us  not  to 
operate  till  the  site  and  nature  of  the  perforation  have  been  deter- 
mined with  some  degree  of  certainty. 

I  believe  that  the  prominence  given  to  perforative  appendicitis 
tends  to  keep  all  other  etiological  factors  in  the  background. 

What  is  true  of  duodenal  ulcer  is  also  true  of  gastric  and  the 
other  numerous  and  genetically  different  forms  of  intestinal  ulcers. 
The  differentiation  between  perforating  ulcer  of  the  csecum  and 
of  the  appendix  can  only  exceptionally  be  made.  In  sudden  per- 
foration this  distinction  naturally  has  no  practical  significance. 

We  are  frequently  called  upon  to  differentiate  between  appen- 
dicitis and  intestinal  obstruction.  In  the  following  section  we  shall 
discuss  chronic  obstruction  as  a  complication  of  appendicitis.  In  the 
cases  there  cited  the  diagnosis  was  easy,  since  the  previous  attack  of 
appendicitis  clearly  indicated  the  original  trouble.  In  acute  cases 
the  differentiation  is  much  more  difficult.  (Compare  also  the  chap- 
ter on  Intestinal  Obstruction,  page  368.)  The  symptoms  may  be 
due  to  a  variety  of  causes.  The  intestinal  obstruction  may  result 
from  reflex  intestinal  paralysis,  from  compression  of  a  perityphlitic 
exudate,  from  kinking  produced  by  adhesions,  or  from  any  other  of 
the  almost  innumerable  ordinary  causes.  If  no  palpable  abscess  be 
present,  the  history  not  definite,  the  temperature  normal  or  almost 
so,  the  patient  collapsed  and  vomiting  faeces,  I  see  no  possibility  of 
distinguishing  between  perityphlitis  and  obstruction.  The  situation 
is  the  more  critical  since  the  circumstances  necessitate  quick  de- 
cision, and  do  not  allow  of  careful  and  thorough  examination  and 
observation. 

In  these  instances  the  laparotomy  will  clear  up  the  diagnosis. 
We  must  again  emphasize  the  value  of  a  careful  history,  which 
may  offer  an  etiological  hint  and  enable  us  to  reach  the  proper 
diagnosis.  The  history  does  not  entirely  guard  against  error,  as 
proved  by  a  case  of  Sonnenburg  ^'^,  in  which  the  history  indicated 
perityphlitis,  but  laparotomy  showed  obstruction  by  gallstones.  It 
is  hardly  necessary  to  state  that  the  above  diagnostic  difficulties  do 
not  always  exist,  and  that  when  the  symptoms  are  typical  the  diag- 
nosis may  be  made  at  sight. 

Typhoid  fever,  particularly  after  perforation,  and  intestinal 
tuberculosis  may  also  be  confused  with  perityphlitis.     When  com- 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  453 

plications  exist,  intestinal  tuberculosis  can  be  differentiated  with 
difficulty  from  perityphlitis.  Borchardt^"  reports  a  case  of  this 
kind. 

The  patient  entered  the  hospital  with  a  pleuritic  effusion  and  diarrhoea. 
Tuberculosis  was  diagnosed.  During  an  illness  of  three  weeks,  symptoms 
pointing  to  the  appendix  were  so  mild  that  they  were  overlooked.  Before 
death  peritonitis  occurred,  which  was  shown  by  the  autopsy  to  have  originated 
from  a  perforated  appendix. 

Where  the  local  symptoms  are  obscure,  the  pain  not  well  local- 
ized, and  the  fever  curve  of  a  continuous  type,  we  must  think  of 
typJioid  fever.  All  the  characteristic  symptoms  of  typhoid  must 
naturally  be  considered,  and  the  Gruber- Widal  serum  test  made.* 
The  differentiation  between  typhoid  fever  and  j)erforative  peri- 
tonitis may  be  very  difficult,  especially  in  recent  cases  with  obscure 
symptoms. 

Septic  (cryptogenetic)  forms  of  appendicitis  may  also  give  rise 
to  diagnostic  errors.  As  shown  by  the  cases  of  Heubner*^  and 
Karewski^,  the  symptoms  are  generally  not  sufficiently  well  de- 
fined, and  the  course  of  the  disease  so  violent  that  the  patient  dies 
before  all  diagnostic  possibilities  can  be  excluded. 

The  cases  of  " pseudo-perityphlitis "  (ISTothnagel)  and  "appendi- 
citis larvata"  (Ewald)  should  also  be  mentioned.  French  observers 
(Talamon  ^^  and  Rendu  ^)  have  described  cases  of  hysterical  perito- 
neal irritation  which  very  closely  resemble  appendicitis,  and  which 
have  been  operated  on.  ]^othnagel  ^^  has  recently  described  a  simi- 
lar clinical  picture  under  the  name  of  "  pseudo-perityphlitis."  Un- 
der the  name  of  "appendicitis  larvata,"  f  Ewald ^^  has  described  a 
train  of  symptoms  in  which  (as  proved  by  subsequent  operations), 
despite  apparent  hysteria,  distinct  changes  occur  in  the  appendix. 

Complications 

These  are  not  infrequent.  They  may  obscure  the  clinical  pic- 
ture, and,  after  the  patients  have  passed  through  the  actual  attack, 
often  cause  death. 

Bossard  aptly  compares  the  inflamed  appendix  to  a  bomb  which 
may  explode  at  any  moment.     The  comparison  is  still  further  true 

*  [The  blood  must  also  be  examined  for  leucoeytosis.  which  is  absent  in  typhoid 
fever  and  present  in  appendicitis  and  suppuration. — Tr.] 

f  As  correctly  stated  by  many  authorities  (Gussenbauei',  J.  Israel,  and  Senator), 
the  designation  "appendicitis  larvata"  may  easily  produce  misunderstanding,  be- 
cause it  contradicts  the  fact  that  all  the  clinical  data  are  present. 
30 


454  DISBASES  OF  THE  INTESTINES 

in  tliat  it  indicates  tlie  many  different  directions  in  which  such  a 
bomb  may  burst. 

All  complications  arise  in  two  ways  :  by  means  of  thrombosis 
and  embolism,  or  by  extension  of  the  inflammatory  process  by  con- 
tiguity. The  latter  is  decidedly  the  more  frequent.  As  we  have 
already  seen,  the  perityphhtic  process  spreads  most  rapidly  down- 
ward (forming  pelvic  and  vaginal  abscesses).  It  may  also  spread  pos- 
teriorly (causing  lumbar  abscesses,  vertebral  abscesses,  etc.),  toward 
the  diaphragm  (subphrenic  abscesses),  toward  the  anterior  abdominal 
wall,  the  hollow  viscera,  and  even  into  the  thorax.  If  rupture 
through  the  abdominal  or  thoracic  wall  takes  place,  a  fistula  may 
result.  It  is  not  our  purpose  to  discuss  all  the  clinical  symptoms 
arising  from  these  complications.  The  resultant  conditions  are  un- 
derstood with  difficulty  when  weeks  or  months  intervene  between 
the  primary  disease  and  the  secondary  complications^,  especially 
when  the  perityphlitic  attack  itself  runs  an  exceedingly  mild 
course. 

Gerhardt  ^  in  particular  has  called  attention  to  the  frequency  of 
pleurisy  as  a  complication  of  appendicitis.  He  has  observed  it 
in  no  less  than  forty-eight  per  cent  of  all  cases  of  appendicitis. 
In  the  great  majority  (forty-two  out  of  fifty)  the  pleurisy  was  on 
the  right  side,  in  seven  cases  on  both  sides,  and  only  once  on  the 
left  side.  The  pleurisy  was  generally  serous ;  in  a  small  number 
there  was  dry  pleurisy.  These  cases  are  most  probably  explicable 
by  the  fact  that  the  inflammatory  process  affects  the  retrocsecal 
connective  tissue ;  from  here  the  process  continues  upward  through 
the  lymph  spaces  of  the  retroperitoneal  cellular  tissue,  advancing 
through  the  diaphragm  to  the  right  pleura. 

The  second  class  of  complications  originate  through  thrombosis 
of  the  appendicular  vein.  Thence  the  thrombotic  particles  are  swept 
into  the  blood  stream  and  reach  a  branch  of  the  portal  vein.  Pyle- 
phlebitis and  multiple  liver  abscesses  develop,  and,  as  observed  by 
Gendron  ^^,  an  abscess  may  rupture  through  the  diaphragm,  causing 
suppurative  pleurisy  and  pericarditis.  Terrillon  ^  has  directed  at- 
tention to  purulent  pleurisy  as  a  comparatively  frequent  complica- 
tion of  appendicitis.  Thrombi  may  become  loosened  from  some  of 
the  branches  of  the  inferior  vena  cava  and  be  carried  as  emboli  to 
the  heart  and  lungs. 

Thrombosis  of  the  iliac  or  femoral  vein  is  a  rare  complication. 
These  thrombi  originate  through  direct  extension  of  the  inflam- 
matory process  to  the  large  venous  vessels,  or  as  the  result  of  stasis 


TYPHLITIS,   PERITYPHLITIS   (APPENDICITIS)  455 

following  compression.  Under  these  conditions,  as  sliown  by  Fow- 
ler, fatal  hsemorrhages  may  occur.  Arterial  thrombosis  is  very 
rare.  Körte  ^^  has  reported  one  case.  Bull  and  Fowler  ^'^  have  pub- 
lished cases  of  rupture  of  abscesses  into  the  iliac  and  femoral 
arteries.  Most  of  these  conditions  can  be  diagnosticated  only  on 
the  autopsy  table.  The  cases  of  suppurative  hepatitis,  pleurisy,  and 
pericarditis,  already  mentioned,  may  be  recognised  during  life, 
but  we  are  rarely  able  to  establish  the  relation  between  them  and 
the  causative  appendicitis. 

An  important  complication  of  appendicitis,  to  which  attention 
was  called  by  Eotter^^,  is  chronic  intestinal  obstruction  by  angular 
kinking  of  the  intestine  in  consequence  of  adhesions.  Two  cases 
were  cured  by  division  of  the  adhesions.  A  case  of  this  kind,  com- 
plicated by  numerous  abscesses,  was  observed  and  brilliantly  diag- 
nosticated intra  vitam  by  IS^othnagel  ^. 

The  infrequent  complication  of  pregnancy  with  perityphlitis 
will  be  briefly  discussed.  Gynecologists  (Abrahams,  Munde,  Hla- 
wacek,  Treub,  McArthur,  Marx,  E.  FränkeP^,  and  others)  teach 
that  appendicitis  during  pregnancy  is  generally  a  very  serious  com- 
plication. Fowler  claims  that  this  complication  always  leads  to 
abortion,  miscarriage,  and  death.  E.  Fränkel  regards  this  as  too 
pessimistic.  As  the  result  of  his  own  observations  and  a  study  of  the 
literature  of  the  subject,  he  has  demonstrated  that  the  gravity  of 
this  condition  depends  upon  the  variety  and  severity  of  the  appen- 
dicitis. In  mild  cases  the  process  may  heal  and  the  pregnancy  run 
its  natural  course ;  in  severe  cases,  localized  or  general  peritonitis 
will  produce  abortion  and  generally  the  death  of  the  mother.*  The 
puerperal  period  may  also  be  endangered  by  appendicitis.  Accord- 
ing to  Fränkel,  there  are  three  possibilities :  1.  In  consequence  of 
uterine  contraction  there  is  a  break  in  the  continuity  of  the  peri- 
appendicular abscess  wall,  with  subsequent  rupture  into  the  free 
peritoneal  cavity  and  general  peritonitis.  2.  Fresh  invasion  of  a 
former  inflammatory  area  by  the  bacterium  coli.  This  invasion 
may  produce  peritonitis  as  well  as  puerperal  infection  of  the  uterus. 
3.  Parametritis  may  develop  from  extension  of  the  appendiceal 
process  to  the  vessels  coursing  in  the  appendicnlo-ovarian  hga- 
ment  (Clado  and  Durand),  or  in  the  retrocsecal  tissue.     In  a  case 


*  [Successful  operations  for  appendicitis  during  pregnancy  with  subsequent 
delivery  at  term  have  been  reported  by  Kraft  "'s,  McCosh ",  Johnson  «o,  Gerster^i 
(two  cases),  and  others.  An  instance  of  recovery  without  operation  and  subse- 
quent delivery  at  term  has  been  published  by  Bayley  ^^. — Tr.] 


456  DISBASES  OF  THE  INTESTINES 

of  probable  induced  abortion  which  came  under  my  observation 
there  occurred  a  severe  aj)pendicitis,  which  was  cured  by  operation. 

Treatment 
Typhlitis 

I  believe  that,  therapeutically  as  well  as  diagnostically,  typh- 
litis should  be  considered  apart  from  appendicitis.  The  treatment  of 
these  two  affections  is  so  entirely  different  that  a  separate  descrip- 
tion is  necessary.  We  have  previously  (page  431)  discussed  the 
different  forms  of  development  of  typhlitis.  Most  of  these  are 
mainly  of  surgical  interest,  and  their  treatment  is  practically  that 
of  appendicitis,  to  which  we  therefore  refer  the  reader.  Medical 
practitioners  are  principally  interested  in  stercoral  typhlitis.  If  the 
physician  agrees  with  us  that,  although  very  rare,  stercoral  typh- 
litis does  occur,  the  therapeutic  methods  to  be  used  become  obvious. 

The  main  treatment  consists  in  the  removal  of  the  impacted 
faeces.  We  should  employ  therapeutic  methods  which  even  in 
appendicitis  do  no  harm,  for  it  is  impossible  to  always  exclude  the 
latter  disease.  As  already  mentioned  (page  189),  I  am  decidedly 
opposed  to  the  administration  of  laxatives.  For  the  purpose  of 
softening  the  faeces  I  use  cleansing  enemata  of  oil,  or  mixtures  of 
castor  oil,  cod-liver  oil,  and  soda.  In  severe  cases  intestinal  irriga- 
tion (page  179)  may  be  used.  By  these  means  we  generally  suc- 
ceed in  softening  the  inspissated  fascal  masses. 

Should  satisfactory  evacuation  follow  these  procedures,  the  intes- 
tine will  require  rest.  For  the  reasons  often  stated,  I  would  warn 
against  repeated  enemata  in  the  expectation  of  more  thoroughly 
cleansing  the  caecum.  On  the  contrary,  after  the  patient  has  had  a 
movement  the  bowels  should  be  constipated  by  opium  sujDpositories 
(0.02  to  0.03  gms.  [of  the  extract?])  or  tincture  of  opium  (twenty 
drops  given  once).  Some  benefit  may  also  be  derived  from  cold 
compresses.  After  three  or  four  days,  when  the  subjective  pain 
and  the  sensitiveness  of  the  csecum  have  ceased  and  the  patient's 
general  condition  is  satisfactory,  another  enema  may  be  given. 

During  the  inflammatory  stage  the  diet  must  be  fluid,  and  gradu- 
ally increased  as  the  inflammation  subsides  and  disappears.  Subse- 
quent treatment  consists  in  preventing  faecal  accumulations ;  when- 
ever possible,  this  is  to  be  accomplished  by  dietetic  means  only, 
aided  perhaps  by  mild  laxatives,  or  still  better  by  enemata.  In  this 
connection  we  refer  the  reader  to  the  chapter  on  Constipation. 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  457 

There  still  remains  an  important  question :  Shall  patients  with 
this  form  of  typhlitis  remain  in  bed  ?  Most  decidedly  they  should. 
The  patient  is  allowed  out  of  bed  only  when  three  days  have  passed 
without  pain,  fever,  or  gastric  disturbances,  when  the  general  con- 
dition is  good,  and  there  is  no  longer  sensitiveness  to  pressure  in 
the  ileo-csecal  region.  After  he  has  left  his  bed  the  patient  must 
be  advised  to  take  care  of  himself  for  several  days. 

Perityphlitis 

(a)  Acute  Perityphlitis 

A  few  observations  regarding  the  possible  prophylaxis  of  peri- 
typhlitis will  not  be  out  of  place.  As  far  as  I  know,  Sahli,  in  his 
Congress  Report,  was  the  first  to  touch  upon  this  subject.  It  was 
later  taken  up  and  discussed  by  Penzoldt^'',  and  moi-e  recently  by 
Ewald  ^.  Authors  are  fairly  well  agreed  that,  to  prevent  a  relapse 
and  to  provide  against  an  attack  of  appendicitis,  constipation  must  be 
controlled.  Where  family  predisposition  toward  appendicitis  exists, 
I  agree  with  these  conclusions.  As  regards  care  to  prevent  the  swal- 
lowing of  seeds,  fish  and  other  bones,  I  consider  these  precautions 
theoretical  rather  than  practical.  The  findings  of  surgeons  in  ap- 
pendicitis operations  do  not  justify  such  precautions.  As  previously 
mentioned,  foreign  bodies  are  found  only  In  a  small  number  of  cases. 

The  treatment  of  perityphlitis  requires  some  preliminary  re- 
marks, by  which  we  hope  to  make  our  general  standpoint  more 
clear.  There  is  no  doubt  that  autopsies  and  operations  have 
already  produced  a  reaction  in  the  treatment  of  appendicitis.  This 
reaction  will  certainly  become  greater  in  the  future. 

Thanks  to  a  large  literary  and  statistical  material  bearing  upon 
the  subject,  the  condition  of  the  appendix  and  its  surroundings  can, 
in  the  majority  of  cases,  approximately  at  least,  be  determined  by 
abdominal  palpation.  This  distinct  advance  in  diagnosis  lends  aim 
and  direction  to  present  therapeusis,  and  at  the  outset  demands 
neither  surgical  nor  internal  therapy,  but  simply  a  plan  which  will 
always  keep  in  mind  the  anatomical  relations  of  the  diseased  pro- 
cesses and  their  influence  upon  the  general  system.  This  stand- 
point permits  at  times  a  surgical  view  of  the  case  on  the  part  of  the 
medical  practitioner,  and  vice  versa.  In  the  therapy  of  appendicitis 
internal  and  surgical  treatment  should  not  and  cannot  be  opposed  ; 
but  when  internal  measures  do  not  sufiice,  surgical  intervention 
should  be  an  aid  to  them. 


458  DISEASES  OP  THE  INTESTINES 

The  internal  treatment,  wliicli  we  shall  now  consider,  must  be 
based  upon  the  following  principles : 

1.  Absolute  bodily  rest. 

2.  Rest  of  the  intestines. 

3.  Appropriate  diet. 

Absolute  rest  in  bed  is  one  of  the  oldest  and  most  important  thera- 
peutic laws.  From  the  moment  appendicitis  is  diagnosticated  the 
patient  must  take  to  bed,  and  not  leave  it  until  the  attack  is  entirely 
over.  Simple  as  are  these  regulations,  they  are  frequently  broken, 
generally  by  the  patient,  but  sometimes  by  the  physician.  In  his 
excellent  treatise  Rotter  has  reported  a  number  of  serious  results 
from  non-observance  of  these  simple  rules. " 

The  most  important  remedy  in  perityphlitis  is  opium,  which  was 
first  employed  by  Yolz.  It  has  a  very  pronounced  immobilizing 
action  on  the  intestines,  reducing  their  movements  and  reflex  irrita- 
bility to  a  minimum.  In  this  manner  salutary  adhesions  may  form, 
the  peritonitis  become  circumscribed,  and,  according  to  Sahli,  the 
shock  of  the  peritonitis  be  lessened.  Opium  has  a  favourable  effect 
upon  vomiting,  loss  of  sleep,  muscular  irritability,  and,  according 
to  Penzoldt,  it  also  lessens  the  thirst.  Finally,  I  would  call  atten- 
tion to  the  little-known  diuretic  action  of  opium,  which,  in  view  of 
intestinal  decomposition,  is  not  without  importance.  In  the  General 
Division  (page  195)  we  have  already  given  the  underlying  princi- 
ples of  the  opium  treatment  of  appendicitis ;  we  shall  here  briefly 
repeat  them. 

In  the  first  days  of  appendicitis,  when  pain,  fever,  and  an  in- 
creasing tumour  are  the  most  prominent  symptoms,  opium  is  espe- 
cially appropriate.  It  should  be  administered  systematically  (tinct. 
opii,  gtt.  XX,  every  three  hours  ;  or  ext.  opii,  0.03  gm.,  t.  i.  d.). 
Suppositories  of  opium,  each  containing  0.05  gm.  ext.  opii,  to  be 
used  t.  i.  d.,  are  also  applicable,  especially  where  internal  adminis- 
tration causes  nausea  or  vomiting.  Provided  a  good  and  active 
preparation  be  at  hand,  the  same  directions  apply  to  opium  given 
subcutaneously  (ext.  opii,  aquos.  sterilizat.,  0.3  gms.  in  10.0  c.  cm. — 
dose,  a  Pravaz  syringeful  t.  i.  d.). 

In  opium  therapy  the  main  rule  must  be  avoidance  of  its  lavish 
use.  When  the  process  has  reached  or  passed  its  highest  point  and 
defervescence  begins,  opium  is  to  be  discarded.  I  would  especially 
warn  against  giving  opium  during  convalescence.  There  is  no 
apparent  reason  for  continuing  the  drug,  and  it  may  produce  intes- 
tinal paresis,  from  which  the  patients  often  suffer  for  the  remainder 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  459 

of  their  lives,  particularly,  as  is  so  often  the  case,  if  there  liad  been 
a  tendency  to  constipation. 

Opium  is  indicated  not  only  in  the  beginning  of  the  disease,  but 
also  in  suppurative  and  perforative  appendicitis  and  in  marked  diffuse 
peritonitis.  In  these  instances  the  doses  must  be  increased  until 
the  pulse  is  slow  and  full,  the  general  condition  satisfactory,  and  the 
facies  composed  (page  195).  In  beginning  collapse  and  in  sepsis 
opium  is  without  efEect ;  in  fact,  it  must  be  changed  for  the  exci- 
tant class  of  remedies. 

Some  authors  prefer  morphin  (subcutaneously)  to  opium.  The 
advantages  of  opium  are  quite  evident.  The  treatment  of  ajDpen- 
dicitis  with  preparations  of  belladonna,  which  has  also  been  recom- 
mended, has  not  yet  been  sufficiently  tested.  Ferrand  ^^  prefers  bella- 
donna to  opium ;  he  claims  it  has  all  the  advantages  and  none  of 
the  disadvantages  of  opium  (suppression  of  intestinal  secretion,  fae- 
cal accumulations,  increase  of  putrefaction).  The  few  cases  I  have 
treated  with  belladonna  are  not  sufficient  for  me  to  express  an  opin- 
ion of  its  effect. 

The  contraindication  to  laxatives  of  all  kinds  follows  directly 
from  the  principle  of  absolute  intestinal  rest.  In  fact,  there  is  sel- 
dom occasion  for  a  laxative.  If  such  necessity  should  arise,  an 
oil  enema  is  by  far  the  most  appropriate  remedy ;  in  these  cases, 
as  Penzoldt  quite  correctly  recommends,  the  physician  should  give 
the  rectal  injection  himself. 

It  need  not  be  emphasized  that  the  greatest  possible  precautions 
are  required  during  the  act  of  defecation. 

Ice  applications  [in  the  form  of  the  ice  bag  or  the  Leiter  coil] 
to  the  ileo-csecal  region  constitute  a  further  immobilizing  agent, 
for  the  patient  is  then  forced  to  lie  absolutely  quiet  on  his  back. 
The  ice  may  also  lessen  the  pain.  We  need  not  fear  peristalsis 
from  the  cold  applications,  for  daily  ex]3erience  has  shown  that 
this,  in  view  of  the  powerful  inhibitory  action  of  the  opium,  is 
scarcely  to  be  considered. 

Ice  is  indicated  as  long  as  inflammatory  symptoms  continue  and 
no  fluctuating  abscess  has  formed.  In  the  latter  instance  ice  is,  to 
say  the  least,  superfluous.  The  physician  is  often  asked  whether 
ice  applications  are  to  be  continued  during  the  night.  This  question 
cannot  be  answered  generically.  If  sleep  be  thereby  hindered,  the 
ice  may  be  removed  and  cold  applications  instead  applied ;  other- 
wise there  is  no  objection  to  the  continuation  of  the  ice  during  the 
night. 


460  DISEASES  OF   THE  INTESTINES 

As  regards  diet,  the  principle  of  greatest  possible  intestinal  rest 
also  applies.  This  finds  its  extremest  exemplification  in  absolute 
starvation  during  the  stage  of  inflammation.  I  do  not  deny  the 
theoretical  justification  of  the  absolute  withdrawal  of  food,  but,  as 
already  stated  (page  151),  I  believe  that  it  is  too  severe  a  measure. 
It  is  justifiable  only  in  an  etiologically  obscure  case  of  peritonitis  or 
of  intestinal  obstruction  with  feecal  vomiting.  In  these  instances, 
subcutaneous  injections  of  salt  or  sugar  solutions  are  the  only  means 
of  subsidiary  nourishment,  but,  with  Penzoldt  and  Ewald,  and  as 
opposed  to  Treves,  I  do  not,  for  obvious  reasons,  consider  nourish- 
ing enemata  indicated. 

The  most  important  dietetic  details  have  been  described  in  the 
General  Division ;  we  can  scarcely  add  to  that  description. 

Besides  treatment  of  the  perityphlitic  attack,  many  cases  require 
appropriate  after-treatment  or  observation.  Regulation  of  the  bow- 
els in  particular  demands  attention.  In  this  connection  we  refer  to 
the  recommendations  given  in  the  chapter  on  Chronic  Constipation. 
After  the  acute  attack  has  passed,  inflammatory  adhesions  or  more 
or  less  exudations  may  remain  ;  the  question  then  arises  how  these 
may  be  best  removed.  In  recent  cases  I  think  it  wisest  to  treat 
these  exudations  expectantly,  and  to  advise  rest  and  general  bodily 
care.  If  the  swelling  persists,  artificial  or  natural  saline  or  mud 
baths  are  often  beneficial,  or  even  curative. 

Massage  is  also  often  advised  for  the  exudations  following  peri- 
typhlitis. We  have  stated  in  the  General  Division  that  massage  is 
to  be  used  only  after  the  inflammatory  symptoms  have  run  their 
course,  and  must  be  practiced  only  by  a  physician  experienced  in 
this  field  of  work.  Other  authors  (e.  g.,  l^othnagel)  advise  against 
massage. 

The  question  regarding  gymnastics  and  sports  must  be  carefully 
decided.  This  question  is  the  more  apt  to  arise  because  appendi- 
citis usually  occurs  at  an  age  when  exercise  is  an  important  factor. 
May  a  mihtary  ofiicer  ride,  a  gymnast  exercise,  a  bicyclist  ride,  an 
oarsman  row  ?  These  questions  must  be  answered  individually  and 
with  the  greatest  reserve.  Under  all  circumstances,  and  for  at  least 
several  months,  exercises  like  the  above  should  be  prohibited.  If  no 
relapse  occurs  and  no  untoward  symptoms  set  in,  we  may  tenta- 
tively allow  the  patient  to  follow  his  special  sport.  Mountain 
climbing,  either  as  a  vocation  or  as  a  pastime,  requires  the  greatest 
caution,  and  should  not  be  extensively  attempted  for  at  least  six 
months  after  the  attack. 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  461 

We  liave  spoken  of  the  use  of  batlis,  jDarticularly  of  saline  and 
mud  baths,  in  the  after-treatment,  especially  whei*e  there  is  consti- 
pation. These  may  be  combined  with  water  cures  (Kissingen, 
Homburg,  Marienbad,  Carlsbad,  Tarasp,  Franzensbad,  Rohitsch, 
Elster,  etc.).  [For  corresponding  American  mineral  springs  and 
wells,  see  page  161. — Tk.]  (Comjiare  also  the  chapter  on  Hydro- 
therapeutics  in  the  General  Division.) 

Operative  Treatment 

In  view  of  the  newness  of  the  operative  treatment  of  appendi- 
citis, and  of  the  customary  separation  of  internal  and  surgical  ther- 
apy, it  is  quite  difficult  for  the  internal  practitioner  to  express  an 
opinion  concerning  the  indications  for  and  the  significance  of 
operation.  Our  judgment  will  therefore  depend  upon  the  experi- 
ence of  surgeons  who  are  acquainted  with  the  results  that  can  be 
obtained  by  internal  treatment. 

At  every  one  of  the  numerous  discussions  within  recent  years 
there  has  arisen  the  preliminary  question :  How  do  the  results  of 
internal  treatment  compare  with  those  of  surgery  ?  Sahli,  Ken- 
vers,  Kleinwächter,  Rotter,  Curschmann,  Aufrecht,  and  others,  have 
l)rought  forward  a  very  impressive  material  to  show  the  curative 
results  of  conservative  treatment.  They  have  thus  doubtlessly 
strengthened  the  cause  of  conservatism,  and  have  contributed  much 
toward  preventing  too  radical  surgical  measures. 

We  quote  Sahli's  statistics,  because  they  are  very  large  and 
therefore  most  trustworthy.  Sahli  ^  collected  the  entire  material 
of  Swiss  physicians,  and  thus  gathered  Y,213  cases.  Of  these, 
473  were  operated  on,  with  a  mortality  of  21  per  cent ;  6,740  were 
treated  conservatively,  with  a  mortality  of  8.8  per  cent.  Relapses 
occurred  in  20.8  per  cent.  The  figures  of  other  medical  practi- 
tioners and  surgeons  only  partly  agree  with  these.  For  instance, 
Kleinwächter  gives  a  mortality  of  7  per  cent ;  Curschmann  and 
Aufrecht  of  4  to  5  per  cent ;  Rotter,  8.9  per  cent ;  Renvers  only  3 
per  cent.  The  same  is  true  of  surgical  statistics,  which  give  a 
varying  mortality  between  9.6  per  cent  (Murphy)  and  2-4  per  cent 
(Richardson),  the  average  being  about  15  per  cent.  It  is  possible 
that  the  mortality  will  be  lowered  by  increased  experience,  early 
operation,  etc.,  but  a  mortality  of  5  to  8  per  cent  will  exist  in  ap- 
pendicitis operations,  no  matter  how  timely  and  successfully  the 
operation  is  performed  (Rotter). 

It  is  useless  to  compare  the  mortality  rates  of  internal  and  sur- 


462  DISEASES  OF  THE  INTESTINES 

gical  treatment.  We  miglit  at  most  compare  tlie  several  groups  of 
appendicitis  with  each  other  (simple  appendicitis,  suppurative, 
perforative,  with  or  without  diffuse  peritonitis,  etc.).  Aside  from 
this  consideration,  as  recently  emphasized  bj  Borchardt,  the  value 
of  statistics  in  determining  the  good  obtained  from  one  or  the 
other  method  of  treatment  is  extremely  doubtful.*  There  are  too 
many  incommensurable  quantities  to  be  considered,  which  in  some 
manner  must  lead  to  a  false  conclusion.  After  all,  the  comparison 
of  hospital  death  rates  would  seem  the  most  reliable.  Even  here 
great  differences  exist.  Thus,  as  the  result  of  internal  treatment  in 
the  St.  Hedwig  Hospital  [Berhn],  in  213  cases  of  appendicitis, 
Rotter  gives  the  low  mortality  of  8.9  per  cent.  In  the  internal 
division  of  the  Ui'ban  Hospital  [Berlin]  the  mortality  of  appendi- 
citis (132  cases)  was  about  12  per  cent  (Borchardt  ^°),  but  of  the  16 
that  died,  about  14  were  admitted  with  an  inoperable  general 
peritonitis.  These  statistics  speak  for  themselves,  and  demon- 
strate that  even  the  cases  which  come  under  the  observation  of 
one  man  are  subject  to  many  accidental  variations.  From  this  it 
follows  that  special  rules  for  individual  cases  cannot  be  laid  down, 
but  that  only  underlying  general  principles  can  be  given. 

For  the  purpose  of  clearness  we  employ  the  usual  subdivisions 
of  appendicitis  into  simple  catarrhal,  suppurative,  and  perforative. 
We  shall  later,  from  the  surgical  standpoint,  discuss  chronic  peri- 
typhlitis. 

Simple  catarrhal  appendicitis  does  not  usually  necessitate  sur- 
gical interference.  Sonnenburg  believes  that  in  these  instances 
the  perityphlitic  attacTc,  and  not  the  perityphlitic  process,  is  cured. 
There  is  not,  however,  any  ground  for  such  conclusion.  Simple 
perityphlitis  will  always  be  a  medical  disease. 

In  circumscribed  suppurative  appendicitis  we  must  distinguish 
between  cases  with  and  those  without  abscess.  In  the  former  group 
there  exists  a  possible  indication  for  operation.  When  the  patient's 
general  condition  is  good  we  may  await  the  absorption  of  the  exu- 
date, which  undoubtedly  takes  place  in  a  large  number  of  cases. 
At  all  events  the  operation  is  generally  simple,  without  danger,  and 
usually  cures  the  suppurative  process  in  a  short  time. 

It  is  quite  a  different  question  whether  the  appendix  itself 
should   be   removed  in   suppurative   appendicitis.     Surgeons  hold 


*  Compare  also  the  brilliant  discussion  of  0.  Rosenbach  regarding  the  value 
of  statistics  in  diphtheria,  in  the  31üneh.  med.  Wochenschr.,  1898,  No.  27. 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  463 

contradictory  opinions  on  this  subject.  As  far  as  I  can  see,  Son- 
nenburg is  the  only  German  surgeon  who  recommends  radical  ex- 
tirpation in  order  to  prevent  relapses.  Fowler  and  Murphy  are  of 
the  same  opinion.  The  majority  of  the  other  surgeons — Körte  ^°, 
Schede  ^'^^  Kotter  ^^,  Mikulicz  "^j  etc. — consider  that  simple  incision  is 
the  proper  procedure,  becaus-e  the  removal  of  the  appendix  is  very 
dangerous  and  sometimes  technically  impracticable.  In  a  case  of 
Gerhardt's  ^,  after  extirpation  of  the  appendix  there  was  a  relapse. 
The  appendix  may  be  removed  when  the  patient  is  not  thereby  en- 
dangered— i,  e.,  when  the  abscess  is  very  small  and  well  encapsu- 
lated, and  also  in  those  cases  where  the  appendix  is  not  walled  oif 
by  adhesions  from  the  general  peritoneal  cavity.* 

Experimental  studies  (Wieland  ^^,  P.  Grawitz  ^'^)  have  demon- 
strated that  the  peritoneum  is  capable  of  absorbing  small  quantities 
of  pus.  Furthermore,  Renvers  has  seen  cases  in  which  the  pres- 
ence of  pus  was  shown  by  exj^loratory  puncture,  cured  by  con- 
servative treatment.  Finally,  during  operations,  inspissated  pus, 
evidently  from  previous  exudates  (Kümmel,  Körte,  and  others),  is 
often  found  in  and  around  the  appendix. 

In  addition  to  the  above,  pus  may  be  eliminated  in  two  ways : 
(1)  By  self -drainage  (Sahli) — that  is,  by  the  pus  emptying  through 
the  ostium  of  the  appendix  itself ;  or  (2)  by  perforation  of  an  extra- 
appendicular  abscess.  Pus  can  only  rarely  be  discovered  in  the 
evacuations  of  the  patients,  but  this  fact  does  not  speak  against 
the  theory  of  self-drainage,  since  pus  in  the  stool  soon  undergoes 
changes  which  may  make  its  recognition  impossible  (Sahli).  On 
the  other  hand,  extension  of  the  suppurative  process  with  diffuse 
peritonitis  is  quite  frequent.  These  cases  are  often  cured  by  sur- 
gical, and  only  exceptionally  by  conservative,  methods.  The  ques- 
tion is  still  further  complicated  by  the  fact  that,  according  to  Pot- 
ter, even  with  general  peritonitis  the  inflammatory  process  may 
become  localized,  lead  to  the  formation  of  an  abscess,  and  therefore 
heal  spontaneously  or  after  simple  incision. 

These  complicated  conditions  make  the  decision  regarding  the 


*  [The  operator  will  have  to  be  guided  by  the  condition  present.  Among 
American  surgeons,  Deaver  ^^  -and  Morton  ^^  favour  the  removal  of  the  appendix 
in  every  instance.  McBurney  ^^  BuU^^  Senn^',  Murphy  ^^  Mynter^^  Fenger^^ 
Fowler^,  and  almost  all  other  noted  surgeons  advocate  a  careful  search  for  and 
removal  of  the  appendix  when  the  patient's  general  condition  permits  of  reason- 
able delay,  and  when  the  location  and  extirpation  of  the  appendix  do  not  neces- 
sitate dangerous  dissection  and  endanger  the  continuity  of  the  abscess  wall. — Tr.] 


464  DISEASES  OP   THE  INTESTINES 

time  for  surgical  intervention  one  of  the  most  difficult  and  respon- 
sible tasks  of  the  physician.  Should  we  operate  while  there  is  still 
hope  that  the  process  will  heal  under  conservative  treatment  ? 
How  long  should  conservative  treatment  be  tried  ?  We  must  not 
foro-et  the  deceptive  similarity  between  convalescence  and  danger. 
What  shall  determine  the  proper  procedure  in  these  cases  :  the  un- 
favourable result  of  internal  treatment,  or  the  successful  results  of 
surgery  ?  JSTot  a  few  cases  have  been  reported  in  which,  both  under 
conservative  and  surgical  treatment,  the  disease  unexpectedly  took 
a  favourable  or  an  unfavourable  termination. 

As  a  general  principle  for  these  cases,  we  would  lay  down  Rot- 
ter's rules  regarding  the  course  of  the  temperature.  He  says  :  "  If, 
despite  proper  internal  treatment,  the  fever  shows  no  tendency  to 
subside,  or  rises  after  the  third  day,  or  if,  after  a  slight  remission, 
the  temperature  after  the  fifth  day  reaches  39°  C.  or  over,  opera- 
tion should  not  be  delayed."  In  such  cases  the  patient's  general 
condition  will  usually  be  disturbed,  and  the  seriousness  of  the  con- 
dition will  be  indicated  by  the  vomiting,  the  frequent,  soft,  irregu- 
lar pulse,  tympanites,  great  bodily  weakness,  sleej^lessness,  marked 
sensitiveness  to  pressure  in  the  ileo-cjecal  region,  and  singultus. 
Rotter  also  says  that  cases  which  at  first  run  a  favourable  course, 
but  which  after  a  number  of  days  again  have  fever,  should  also  be 
operated  on.  In  all  these  instances  an  abscess  is  present,  and  if  not 
incised  may  lead  to  serious  complications. 

Those  cases  which  immediately,  or  after  twenty-four  to  forty- 
eight  hours,  have  signs  of  diffuse  septic  peritonitis,  are  undoubtedly 
surgical,  and  the  sooner  they  are  placed  under  the  surgeon's  care 
the  better.  Here,  as  already  mentioned,  the  great  difficulty  fre- 
quently lies  in  the  diagnosis.  The  majority  of  these  patients  can 
scarcely  stand  narcosis,  let  alone  operation  ;  hence  the  surgical  re- 
sults are  not  very  encouraging.  Thus,  despite  timely  operation. 
Rotter  lost  sixty-six  per  cent,  Körte  sixty-four  per  cent,  and  Son- 
nenburg ^'^  fifty-eight  per  cent  of  such  cases.  Every  successful  re- 
sult must  be  regarded  as  a  direct  gain. 

(5)   Chronic  Perityphlitis 

Concerning  this  affection  a  proper  understanding  is  beginning 
to  exist  between  medicine  and  surgery.  We  have  already  studied 
the  two  forms  of  chronic  appendicitis :  chronic  appendicitis  in  its 
narrower  sense,  and  relapsing  appendicitis.  Under  certain  condi- 
tions both  forms  may  be  accompanied  by  severe  symptoms,  which 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  465 

disturb  the  patient  and  interfere  with  his  abihtj  to  do  work,  or 
even  endanger  his  existence. 

We  must,  liowever,  remember  that  great  care  and  tlie  use  of 
appropriate  remedies  (baths,  springs,  and  diet)  will  remove  many 
of  the  patient's  symptoms,  and  that  relapses  are  often  much  milder 
and  do  not  last  as  long  as  the  primary  attack.  Finally,  as  Eotter  ^^ 
and  Kümmell*^  have  shown,  relapses  are  much  more  frequent 
within  the  first  year  following  the  primary  attack,  decrease  in  fre- 
quency in  the  second  and  third  years,  and  are  very  rare  thereafter. 
The  results  of  surgical  treatment  are  exceptionally  favourable ; 
Kümmell  ^^ ,  who  has  had  the  most  experience  in  relapsing  appendi- 
citis, does  not  consider  removal  of  the  appendix  more  dangerous 
than  an  ordinary  ovariotomy. 

The  social  status  and  vocation  of  the  patient  are  of  great  impor- 
tance in  deciding  for  or  against  operation,  A  patient  so  situated  that 
he  may  take  every  possible  care  of  himself  need  not  decide  upon  an 
operation  as  rapidly  as  one  who  must  work  hard  for  a  living. 

Hence,  the  following  indications  for  operative  interference  in 
chronic  appendicitis  may  be  laid  down  : 

1.  If,  after  an  acute  attack  of  appendicitis,  severe  and  other 
disturbances  (pain,  sensitiveness,  etc.)  persist,  operation  is  to  be 
performed  as  soon  as  possible  in  those  whose  vocation  necessitates 
work.  In  other  cases  operation  is  indicated  only  after  other  reme- 
dies have  failed. 

2.  In  relapsing  appendicitis,  especially  among  the  working  classes, 
operative  interference  is  indicated  when  the  attacks  occur  at  short 
intervals  and  become  more  and  more  severe.  If  the  interval 
between  the  primary  and  the  next  succeeding  attack  is  more  than 
three  years,  operation  may  be  delayed  or  advised  against. 

Borchardt  gives  two  further  indications  which,  for  the  purpose 
of  completeness,  we  here  repeat : 

{a)  In  women,  operation  is  indicated  when  the  adnexa  are 
affected  by  the  inflammatory  process.  Early  operation  may  pre- 
vent infection  of  the  adnexa  of  the  left  side. 

(h)  Operation  is  indicated  when,  as  a  consequence  of  adhesions 
between  the  appendix  and  the  female  adnexa,  severe  symptoms  occur 
during  pregnancy,  which  tend  to  produce  abortion  or  miscarriage. 

Finally  a  few  remarks  on  the  operative  treatment  of  tubercidar 
appendicitis  are  in  place.  We  have  previously  stated  that,  accord- 
ing to  literature,  this  class  of  cases  concerns  individuals  with  a 
tubercular  constitution  in  whom  the  appendicitis  is  only  a  compli- 


4,eG  DISEASES  OF   THE  INTESTINES 

cation.  In  my  opinion,  operation  in  these  instances  is  as  little  indi- 
cated as  in  a  tubercular  kidney  with  marked  pulmonary  phthisis. 
The  few  cases  which  were  operated  (Körte  and  Sonnenburg)  died 
in  a  short  time,  Borchardt  reports  two  cases  of  tuberculosis  of  the 
caecum  with  fistulse  in  the  ileo-csecal  region.  Both  patients  died 
soon  after  operation. 

The  prognosis  after  operative  treatment  of  actinomycotic  appen- 
dicitis is  also  unfavourable.  Of  the  twelve  cases  reported  in  Son- 
nenburg's  monograph  (to  which  we  add  another  case  recently 
reported  by  Karewski  ^^ )  only  one  was  cured. 

In  conclusion,  a  few  remarks  on  the  relation  between  the  physi- 
cian and  the  surgeon  appears  to  me  appropriate.  We  consider  it 
very  desirable  that,  wherever  possible,  in  every  case  of  apparently 
severe  appendicitis  a  surgeon  shall  be  immediately  consulted.  It  is 
not  necessary  to  operate  at  once,  but  the  case  is  to  be  observed 
and  studied  by  both  practitioners,  and  the  proper  time  for  surgical 
interference  watched  for.  In  public  hospitals  this  is  readily  accom- 
plished, but  in  private  practice  it  should  be  followed  to  a  greater 
extent.  The  surgeon  who  in  a  given  case  decides  for  conservative 
measures  instead  of  for  operation,  will  not  lose,  but  gain,  in  repu- 
tation. 

[The  preceding  chapter  describes  very  fully  the  modern  conti- 
nental view  of  appendicitis,  particularly  from  the  standpoint  of  the 
general  practitioner.  Whether  from  climatic,  racial,  dietetic,  or 
other  influences,  the  type  of  the  disease  in  Europe  is  a  far  milder 
one  than  in  the  United  States,  or  whether,  because  less  prevalent, 
its  gravity  is  not  so  fully  appreciated,  certain  it  is  that  the  medical 
profession  abroad  regard  appendicitis  in  a  far  more  sanguine  light 
than  we  do  in  this  country.  It  appears  therefore  in  place  to  sum- 
marize the  American  ideas  of  appendicitis  as  gathered  from  litera- 
ture and  personal  experience. 

Within  recent  times  no  other  affection  has  been  the  subject  of 
so  much  discussion,  demonstration,  study,  and  writing.  In  this 
country,  appendicitis  is  of  such  frequency  that  almost  every  layman 
is  acquainted  with  its  manifestations  and  dangers.  Fitz's^^  masterly 
monograph  taught  us  the  proper  significance  of,  and  gave  the  impetus 
to,  the  further  study  of  ileo-csecal  inflammations.  The  brilliant 
operative  results  of  Morton  %  Sands  ^■^,  McBurney  ^^,  Weir^*,  and 
others  demonstrated  practically  what  Fitz  theoretically  tanght, 
viz.,  the  possibilities  of  surgery  in  this  domain,      ßapidly  experi- 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  457 

ences  multiplied,  definition  in  diagnosis,  prognosis,  and  treatment 
became  more  exact,  and  to-daj  the  clinical  phases  of  the  disease  are 
far  better  understood.  We  have  come  to  regard  appendicitis  essen- 
tially as  a  surgical  condition,  and  one  which  must  therefore  be 
treated  upon  strictly  surgical  principles.  It  is  everywhere  recog- 
nised by  general  practitioners  that  each  case  of  appendicitis  ought 
(at  least  in  large  cities)  to  be  treated  by,  or  in  conjunction  with,  a 
competent  surgeon.*  This  fact  is  also  understood  by  our  general 
public ;  and  once  the  diagnosis  is  made  or  suspected,  the  possibility 
of  an  immediate  or  future  operation  is  entertained.  In  all  our 
hospitals  patients  with  appendicitis  are  assigned  to  the  surgical 
di  vision. f 

The  terms  typhlitis,  csecitis,  iliac  abscess,  pericsecal  abscess,  and 
perityphlitis,  though  still  mentioned  in  text- books  and  monographs 
have  been  completely  dropped  in  practice.  That  primary  inflam- 
matory (suppurative)  conditions  of  the  caecum  may  occur  is  not 
denied,  but  if  they  do  occur  they  must  be  exceedingly  rare,  and 
clinically  indistinguishable  from  appendicular  processes ; ;{:  there- 
fore no  practical  value  attaches  to  their  separate  consideration. 
Clinically,  at  least,  the  diagnosis  "  appendicular  (vermicular)  colic  " 
is  never  made  in  this  country,  for  that  condition  is  regarded  as 
identical  with  a  mild  form  of  catarrhal  appendicitis  (Hartley ''"'', 
Fowler  *), 

For  the  reasons  stated  at  length  in  the  main  body  of  the  present 
chapter,  and  which,  together  with  a  few  additional  facts,  shall  now 
be  briefly  recapitulated,  aj)pendicitis  differs  essentially  from  other 
inflammatory  and  ulcerative  processes  of  the  intestines. 

The  vermiform  appendix  in  man,  being  in  an  evolutionary  state, 
has  a  natural  tendency  toward  obliteration ;  hence  it  can  offer  but 
a  feeble  resistance  to  deleterious  influences.     Owing  to  its  very  rich 


*  ["  It  must  be  confessed  that,  according  to  our  present  views,  appendicitis  is  a 
surgical  rather  than  a  medical  affection,  particularly  from  the  standpoint  of  treat- 
ment "  (Anders  9*).] 

["  The  disease  is,  properly  speaking,  a  surgical  one  "  (Lockwood '").] 

["  In  the  majority  of  instances  appendicitis  is  a  surgical  affection,"  wriies 
Pepper^',  one  of  the  strongest  advocates  of  the  opium  treatment.] 

f  [Osier  ^8  remarks  :  "  So  impressed  am  I  by  the  fact  that  we  physicians  lose  lives 
by  temporizing  with  certain  cases  of  appendicitis,  that  I  prefer,  in  hospital  work, 
to  have  the  suspected  cases  admitted  directly  to  the  surgical  side."] 

X  [According  to  McBurney,  99  per  cent  of  all  typhlitic  abscesses  are  of  appen- 
dicular origin.] 

*  [Loc.  cit.,  p.  45.] 


468  DISEASES  OF  THE  INTESTINES 

lymphatic  structure,  excessive  secretion  readily  results  from  irrita- 
tion. The  disproportion  between  the  length  and  the  diameter  of 
its  lumen,  the  scarcity  of  contractile  muscle  fibres,  the  presence  of 
fsecal  concretions  and  of  Gerlach's  valve,  and  of  other  physiological 
strictures,  and  the  pendent  position  of  the  organ,  favour  the  stag- 
nation of  this  excessive  secretion.  As  a  result,  there  is  increased 
pressure  within  the  appendix.  Concretions  and  other  foreign 
bodies  produce  erosions  and  ulcerations  of  the  wall.  The  nutrient 
vessels  being  terminal  branches,  there  is  no  provision  for  the  estab- 
lishment of  compensatory  anastomosis,  the  circulation  is  readily 
embarrassed,  and,  unless  the  stagnation  within  the  lumen  is  relieved, 
gangrene  results.  The  presence  of  bacteria  adds  an  infectious  ele- 
ment to  the  process,  and  may  lead  to  the  formation  of  an  abscess 
within  the  appendix  (empyema),  or  (with  or  without  perforation)  to 
suppurative  processes  in  the  surrounding  parts.  General  sepsis 
may  also  occur. 

Usually  the  changes  involve  the  entire  appendix.  Hartley'''' 
states  that  some  appendices  which  he  had  removed  in  the  first 
twenty-four  to  forty-eight  or  even  seventy-two  hours  of  the  dis- 
ease, showed  changes  only  in  the  mucosa  and  submucosa.  If  the 
serous  coat  becomes  affected,  a  local  peritonitis,  with  the  formation 
of  more  or  less  extensive  adhesions,  results.  "  These  adhesions  may 
repeatedly  form  an  efiicient  protective  wall,  but  often  they  are 
powerless  to  prevent  the  further  spread  of  a  purulent  peritonitis. 
This  is  the  most  important  phase  of  the  pathology  of  appendicitis, 
and  is  a  condition  which  we  will  never  be  able  to  overcome " 
(Stein  ^^).  The  existence  of  such  a  condition  is  a  strong  argument 
against  waiting  for  an  abscess  to  become  absorbed,  or  against  delay- 
ing the  operation  until  firm  adhesions  have  formed.  In  very  acute 
cases  the  infective  process  may  spread  so  rapidly  that  there  is 
no  time  for  adhesions  to  form,  and  an  acute  general  peritonitis 
supervenes. 

In  addition  to  empyema,  ulceration,  and  perforation,  the  appen- 
dix may  be  the  seat  of  other  pathological  changes,  particularly 
where  there  have  been  repeated  attacks.  Strictures  and  cystic  con- 
ditions may  develop,  the  lumen  may  be  obliterated,  or  the  wall  of 
the  appendix  become  thickened  and  indurated.  Sometimes  the 
entire  appendix  is  embedded  in  a  mass  of  adhesions,  and  loses  its 
original  appearance  and  character. 

JSTo  new  facts  relative  to  the  conservative  treatment  can  be  added 
to  those  described  on  page  458.      It  is  well,  perhaps,  to  briefly 


TYPHLITIS,    PERITYPHLITIS   (APPENDICITIS)  409 

define  the  position  assumed  in  this  country  in  regard  to  opium  and 
cathartics. 

As  in  other  countries,  views  differ  regarding  the  propriety  of 
prescribing  opium  and  its  alkaloids  in  appendicitis.  In  private 
practice  there  is  a  constantly  increasing  tendency  to  limit  their 
employment.  Surgeons,  as  a  rule,  condemn  their  administration, 
at  least  until  the  diagnosis  has  been  made  or  operation  decided  U23on. 
Even  then  opium  should  be  used  in  minimum  amounts,  just  sufficient 
to  relieve  pain.  It  has  been  stated  that  a  pain  unrelieved  by  an 
ice  bag,  etc.,  and  severe  enough  to  require  large  doses  of  opium, 
constitutes  in  itself  a  sufficient  indication  for  operation  (Wiener  ^*'''). 
The  objections  to  opium  are :  («)  That  it  masks  the  symptoms  and 
produces  a  false  euphoria,  rendering  it  impossible  to  properly  esti- 
mate the  attack  ;  {b)  that  it  favours  the  development  of  a  tympani- 
tis which  we  may  be  unable  to  differentiate  from  that  of  a  begin- 
ning peritonitis  (Wiener) ;  and  (c)  that  in  large  doses  it  is  apt  to 
induce  an  intestinal  paralysis.  The  points  in  favour  of  its  use  have 
already  been  mentioned  (page  458).  Pepper^  considers  opium  in 
full  doses  as  "  the  great  standby,"  and  that  it  has  greatly  lessened 
the  mortality  from  appendicitis.  Einhorn  ^"^  considers  oj)ium  the 
remedy  par  excellence.  Deaver^"^  permits  its  use  for  the  relief  of 
pain,  but  only  after  a  purgative  action  has  been  obtained;  he  con- 
siders the  local  use  of  ice  much  better  than  the  administration  of 
opium.  Lockwood  ^^  also  would  give  opium,  but  not  to  the  extent 
of  semi-narcotism. 

The  use  of  cathartics  is  still  a  disputed  question.  Recently 
salines  were  extensively  employed  and  recommended  by  surgeons. 
Deaver  ^'^^  claims  never  to  have  seen  any  harm  from  catharsis.  lie 
certainly  does  not  voice  the  general  opinion  when  he  says  :  "  Pur- 
gatives are  capable  of  doing  much  more  good  under  these  circum- 
stances than  any  other  class  of  drugs.  ...  I  am  positive,  after  con- 
siderable experience,  that  the  good  from  purging  will  overbalance 
by  far  the  harm  done  by  active  peristalsis.  The  writers  who  oppose 
the  use  of  these  drugs  are  evidently  limited  in  their  experience 
with  the  disease,  otherwise  they  would  not  so  believe."  Tiffany  ^''^ 
also  favours  free  purging.  In  general,  both  medical  and  surgical 
authorities  condemn  their  use  during  an  acute  attack  (Osier  ^^,  Mc- 
Burney «^  Einhorn  ^^\  McN'utt  ^%  Mynter  ^\  Pepper  ^',  etc.).  Tyson  ^''^ 
opposes  their  employment  in  advanced  cases,  but  thinks  their  early 
administration  in  mild  or  moderate  cases  may  clear  up  the  diagnosis, 
or,  by  depletion  of  the  circulation,  diminish  the  danger  of  peritonitis. 
31 


470  DISEASES  OP  THE  INTESTINES 

Against  tlie  use  of  cathartics  it  is  urged  that  they  are  not  needed, 
•since  the  csecum  is  rarely  filled  with  faecal  accumulations ;  that  cathar- 
tics tend  to  increase  nausea  and  general  unrest ;  and  that  by  exciting 
peristalsis  they  prevent  the  formation  of  fresh  adhesions,  and  break  up 
those  already  formed,  but  not  yet  firm.  Finally,  it  must  not  be  lost 
sight  of  that,  even  in  the  very  earliest  stages  of  appendicitis,  we  can 
never  tell  how  near  the  appendix  is  to  perforation.  Hence,  in  gen- 
eral, it  is  best  to  defer  the  administration  of  purgatives  until  after 
operation,  or  until  the  attack  has  passed  oif.  If  it  be  necessary  to 
empty  the  lower  bowel  earlier,  an  enema  will  answer  very  well. 

What  are  the  recognised  indications  for  operation  ?  In  endeav- 
ouring to  answer  this  question  the  writer  has  consulted  the  publica- 
tions of  recognised  American  authorities,*  and  has  also  drawn  upon 
personal  experience  in  hospital  and  private  practice.  He  finds  that 
there  has  been  a  considerable  change  of  opinion  since  the  clinical 
and  pathological  manifestations  of  appendicitis  have  received  more 
direct  attention.  In  the  earlier  days  it  was  universally  recom- 
mended to  wait  until  an  abscess  had  formed.  The  discovery  and 
publication  of  McBurney's  point  ^°^  was  a  most  decided  advance  in 
the  early  diagnosis  of  acute  appendicitis.  Taught  by  sad  ex- 
periences, the  American  profession  has  come  to  appreciate  the 
dangers  which  attend  postponement  of  operation,  and,  emboldened 
by  the  success  of  modern  surgical  methods,  has  learned  to  be  more 
radical  in  its  treatment  of  appendicitis. 

We  recognise  that  owing  to  anatomical  peculiarities,  an  appen- 
dix once  the  seat  of  a  more  than  very  slight  inflammation  will  never 
return  to  its  normal  state,  and  that  this  predisposes  the  organ  to 
fresh  attacks.  We  believe  that  with  each  fresh  attack  the  patho- 
logical state  of  the  appendix  is  aggravated.  There  are  no  specific 
internal  remedies  for  the  cure  of  appendicitis.  Treated  conserva- 
tively, mild  cases  often  recover  with  a  restitutio  ad  integrum,  or 
with  no  further  changes  than  strictures  of  the  lumen ;  severer 
cases  may  be  attended  by  any  of  the  processes  already  mentioned. 
Exceptionally,  an  extra  appendicular  abscess  ruptures  externally  or 
into  a  hollow  abdominal  viscus  (bladder,  caecum,  rectum,  etc.),  and 
relief  or  spontaneous  cure  follows.f 

The  abscess  has  occasionally  perforated  the  diaphragm  and  dis- 

*  [See  Literature  at  the  end  of  this  chapter.] 

f  [Lloyd  ^''■'  reports  a  very  interesting  and  instructive  instance  of  acute  appen- 
dicitis occurring  in  a  man  in  whom  years  before  a  peri-appendicular  abscess  had 
ruptured  and  discharged  into  the  rectum.] 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  471 

charged  tlirougli  the  lung.  The  danger  and  inconvenience  of  such 
conditions  are  too  apparent  to  call  for  any  comment. 

In  the  vast  majority  of  cases  we  are  unable,  without  laparotomy, 
to  determine  the  condition  in  the  ileo-caecal  region.  We  cannot 
tell  how  near  the  appendix  is  to  perforation ;  whether  there  are  any 
adhesions,  and,  if  so,  how  firm ;  whether  there  will  be  any  further 
attacks,  etc.  To  guide  us  in  our  disposal  of  a  case,  we  must  appeal 
to  our  experience  and  the  results  of  pathological  research. 

With  but  few  exceptions  the  profession  have  therefore  come  to 
regard  appendicitis  as  a  surgical  affection.  This  applies  as  well  to 
the  simple  catarrhal  as  to  the  suppurative  and  other  severer  forms. 
If,  then,  during  a  slight  or  moderately  severe  acute  attack  we  resort  to 
rest  in  the  recumbent  position,  an  ice  bag,  restricted  diet,  and  other 
conservative  measures,  in  the  endeavour  to  tide  the  patient  over  the 
attack,  we  are  none  the  less  fully  alive  to  the  possibility  of  an  im- 
mediate or  the  probability  (almost  certainty)  of  a  future  operation. 
We  watch  our  cases  very  carefully,  and  are  prepared  for  immediate 
surgical  interference  should  indication  arise.  Experience  has  taught 
that  the  period  of  quiescence  between  attacks  offers  the  best 
chances  for  operative  success.  The  patient  or  his  friends  are  in- 
structed concerning  the  gravity  of  the  situation,  and  such  details  are 
explained  to  them  as  are  necessary  for  their  clearer  judgment.  For 
with  the  family,  after  all,  will  rest  the  consent  to  operate. 

Contraindications  to  Operation. — Besides  the  withholding  of 
the  consent  of  the  patient  or  those  responsible  for  him,  operation 
may  be  impossible  or  inadvisable  for  other  reasons.  Such  would 
be  inadequate  surroundings,  failure  to  obtain  proper  assistance,  sur- 
gical inexperience  of  the  medical  attendant,  too  far  advanced  con- 
dition of  the  case  (sepsis,  extreme  weakness,  moribund  state,  etc.) 
coincidence  of  other  serious  disease,  etc. 

In  the  absence  of  these  adverse  circumstances  the  following  are 
the  generally  accepted  indications  for  operation :  * 

I.  Interval  operation. f 

(a)  In  mild  cases  after  two  or  more  attacks. 

*  [The  following  indications  apply  only  to  patients  residing  in  large  cities  or 
otherwise  accessible  to  immediate  surgical  interference.  For  those  who  travel 
much,  who  live  in  the  country,  or  who  must  perform  severe  physical  labour,  etc.,  it 
is  best  to  remove  the  appendix  during  or  after  a  first  attack.] 

f  [It  is  best  to  wait  about  two  to  four  weeks  after  even  mild  attacks,  until  the 
inflammation  has  become  quiescent.  The  mortality  under  such  circumstances, 
even  in  difficult  and  unfavourable  cases,  is,  in  the  hands  of  a  good  operator,  1  per 
cent  or  3  per  cent  (McBurney).] 


472  DISEASES  OP  THE   INTESTINES 

Willy  Meyer  ^"^^  advises  the  radical  operation  after  recovery 
froiQ  any  attack  of  appendicitis,  mild  or  severe.  Deaver^^,  Myn- 
ter^®,  and  a  few  other  surgeons,  favour  immediate  operation  in  all 
cases  of  appendicitis  as  soon  as  the  diagnosis  is  made. 

(h)  After  recovery  from  an  attack  of  ordinary  or  more  than 
ordinary  severity. 

Here  general  practitioners  and  surgeons  are  almost  unanimously 
agreed  that  it  would  be  assuming  too  great  a  risk  to  expose  the 
patient  to  the  dangers  of  a  repeated  attack. 

II.  Immediate  operation. 

1.  In  cases  of  ordinary  severity  with  sharply  defined  symptoms. 
(a)  Whenever  there  is  a  tumour  present  in  the  ileo-cgecal  region. 
(h)  Whenever  there  is   sudden  or   progressive  increase  in  the 

gravity  of  the  symptoms. 

(c)  When,  after  thirty-six  to  forty-eight  hours,  the  case  does 
not  show  any  tendency  toward  improvement,  but  the  condition 
remains  stationary.f 

{d)  Whenever  there  is  any  doubt  as  to  the  existing  condition 
and  the  patient's  improvement  most  authorities  advise  immediate 
operation.  In  this  instance  timely  operation  is  better  than  the  un- 
certainty and  dangers  which  attend  delay .:|; 

2.  In  all  the  severer  forms  of  appendicitis — i.  e.,  those  in  which 
the  symptoms  point  to  pus  in  or  about  the  appendix  (with  or  with- 
out peritonitis),  to  perforation,  or  to  severe  systemic  infection — we 
cannot  operate  too  early.  It  is  wrong  to  delay  and  attempt  to 
determine  the  pathological  conditions  present,  for  we  will  rarely 
arrive  at  more  than  a  probable  diagnosis,  and  every  delay  may  cost 
the  patient  his  life.  In  all  cases  of  acute  appendicitis  the  earlier 
the  operation  the  easier  its  performance,  the  better  the  condition  of 
the  patient,  and  the  more  certain  are  the  chances  of  success. — Te.] 

*  [Willy  Meyer  reminds  us  that  the  first  attack  is  really  not  the  first  pathologi- 
cal symptom,  but  rather  the  "  first  explosion."] 

f  [Here  one  must  be  guided,  in  advising  immediate  or  interval  operation,  by 
the  existing  circumstances,  particularly  by  the  general  condition  of  the  patient  and 
the  care  with  which  the  case  can  be  watched.] 

I  [McBurney  ^^,  one  of  our  greatest  authorities  on  appendicitis,  says,  in  referring 
to  this  indication  for  operation :  "  No  greater  mistake  can  be  made  than  to  wait 
for  very  clearly  defined  signs  of  advanced  and  grave  disease  before  deciding  to 
operate.  Operation,  to  be  usually  successful,  must  be  done  before  grave  disease  is 
well  pronounced."] 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  473 

APPENDIX 
Sigmoiditis  and  Pericolitis 

(a)  Acute  Sigmoiditis 

Under  this  name  A.  Mayor  ^^  has  described  a  condition  which 
consists  in  an  inflammation  of  the  sigmoid  flexure  and  occasionally 
of  the  neighbouring  peritoneum  and  cellular  tissue  ("iliac  phleg- 
mon"). Mayor  believes  that  this  affection  is  caused  by  faecal 
impaction  in  the  sigmoid  or  by  irregular  defecation.  Both  causes 
may,  however,  be  absent.  Fever  may  or  may  not  be  present.  The 
region  of  the  sigmoid  is  always  indurated,  swollen,  and  sensitive  to 
j3ressure ;  suppuration  and  rupture  into  the  intestine  may  occur. 
All  the  cases  were  marked  by  rapid  convalescence.  Mayor  leaves 
it  undecided  whether  the  disease  is  produced  by  purely  mechanical 
factors  or  by  specific  infection  (e.  g.,  erosions). 

To  illustrate  the  clinical  picture,  it  seems  best  to  present  a  brief 
analysis  of  the  clinical  histories  reported  by  Mayor : 

Case  I. — A  woman,  thirty-two  years  old,  who,  excepting  for  constipation, 
liad.  always  been  well.  On  examination  of  the  region  of  the  sigmoid  flexure, 
tliere  was  felt  a  cylindrical  swelling  which  was  continuous  with  the  descend- 
ing colon  above,  and  disappeared  toward  the  pelvis.  Rectal  examination 
showed  nothing  abnormal.  Tliis  condition  developed  without  fever,  and 
disappeared  under  the  use  of  cataplasms. 

Case  II. — Boy,  fourteen  years  old,  became  ill  with  fever,  pain  in  the  left 
side,  and  local  symptoms  similar  to  the  above ;  after  fever  for  several  days  the 
boy  recovered. 

Case  III. — Boy,  eleven  years  old,  became  ill  with  high  fever;  suppuration 
occurred,  and  the  abscess  ruptured  into  the  intestine. 

Case  IV. — Physician,  forty-two  years  old,  sudden,  severe,  paroxysmal 
pains  in  the  sigmoid  region,  accompanied  by  nausea;  no  constipation,  no  fever. 
The  sigmoid  flexure  was  indurated,  swollen,  and  sensitive.  Recovery  after  a 
few  days. 

In  a  case  recently  reported  by  Galliard,'"'  there  were  severe  general  symp- 
toms, with  fever,  and  pain  in  the  left  iliac  fossa.  There  was  a  tumour  the  size 
of  an  orange,  which  disappeared  after  three  weeks. 

In  the  absence  of  autopsies,  certainty  regarding  the  pathogenesis 
of  the  disease  is  scarcely  possible.  It  seems  very  diflicult  to  differ- 
entiate acute  sigmoiditis  from  inflammation  of  the  csecum,  or  an 
appendix  displaced  to  the  left.  Chronic  enteritis  with  acute  exacer- 
bations may  also  be  mistaken  for  sigmoiditis,  especially  since  fever 
is  not  a  necessary  symptom  of  the  latter.  Finally,  inflammation  of 
the  left  female  adnexa  may  also  require  diagnostic  consideration. 


4Y4  DISEASES  OF  THE  INTESTINES 

Mayor  deserves  credit  for  having  pointed  out  that  inflammatory 
processes  may  occur  in  the  left  ihac  fossa.  Further  study  of  these 
conditions,  and  the  knowledge  derived  from  operative  procedures, 
will  be  required  before  we  can  say  that  there  is  proper  justification 
for  considering  this  affection  as  an  inflammation  of  the  sigmoid 
flexure. 

The  same  treatment  must  be  applied  as  in  typhlitis  :  rest  in  bed, 
ice,  or,  when  this  is  not  well  borne,  warm  applications,  regulation  of 
the  bowels,  and  opium  (internally,  subcutaneously,  or  in  supposi- 
tories) when  the  pain  is  severe. 

(5)  Chronic  Sigmoiditis 

By  chronic  sigmoiditis  I  mean  an  affection  in  which  there  is 
constant  pain  and  sensitiveness  to  pressure  in  the  region  of  the 
sigmoid  flexure.  Further  symptoms  are  severe  diarrhoea,  accom- 
panied by  more  or  less  mucus,  or  by  attacks  of  constipation. 

Yon  Leube  '^'^  and  Rosenheim  ''^^  also  report  chronic  inflammatory 
infiltration  of  the  sigmoid  flexure  with  a  "  smooth,  regular,  increased 
resistance."  Since  chronic  sigmoiditis  is  but  little  known,  I  will 
briefly  report  two  cases  from  my  journal : 

Case  I. — Mrs.  F.  R.,  of  Berlin,  age  thirty-nine.  No  hereditary  disease ; 
has  had  four  severe  labours  and  two  abortions,  produced,  she!  says,  by  falling  and 
jolting.  Her  present  symptoms  have  lasted  eleven  years,  and  are  ascribed  by 
her  to  the  first  confinement,  which  was  an  instrumental  delivery  with  complete 
tear  of  the  perinseum.  A  recto-vaginal  fistula  remained,  and  caused  the  patient 
much  annoyance.  Three  years  later  the  fistula  was  operated  on  by  Prof. 
Fritsch.  Patient  felt  better  for  a  few  months  after  the  operation,  but  the  symp- 
toms gradually  returned,  and  at  present  they  are  at  their  greatest  intensity. 
They  consist  of  pains  in  left  lower  abdominal  quadrant,  flatus,  and  morning 
diarrhoea  (two  to  four  movements)  with  much  mucus.  Blood  has  never  been 
found  in  the  stools.  Frequent  tenesmus,  which  only  ceases  after  injections  of 
chamomile  infusion.  The  diarrhoea  alternates  with  normal  stools  for  one  to  two 
days.  On  such  days  the  patient  feels  much  better.  The  other  gastro-intestinal 
functions  are  absolutely  normal.  All  treatment  (oil  enemata,  opium,  tannalbin, 
etc.)  has  been  without  effect  up  to  the  present  time. 

Status  Proesens. — Pale,  well-nourished  woman.  Organs  of  respiration  and 
circulation  normal. 

AMomen. — Many  striae,  abdominal  j)anniculus  flabby  (pendulous  abdomen), 
splashing  and  succussion  sounds  in  the  gastric  region.  Lower  border  of  the 
stomach  (carbonic-acid  inflation)  reaches  to  the  umbilicus. 

The  slightest  palpation  in  the  region  of  the  sigmoid  is  extremely  painful. 
As  the  examining  finger  passes  upward  the  sensitiveness  becomes  less,  and  at 
the  splenic  flexure  disappears  entirely.  No  resistance  to  be  felt.  Rectal  exam- 
ination negative. 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  475 

Urine. — Normal;  no  indicanuria. 

Stools. — Two  to  three  stools  daily,  of  semisolid  consistency,  and  mixed 
with  viscid  mucus.  Microscopically  nothing  of  importance,  particularly  no 
blood,  pus,  or  amoebae. 

Stomach. — Motility  normal,  marked  hyperacidity  (0.28  per  cent  HCl). 

During  the  clinical  examination  there  were  six  to  seven  thin  stools,  accom- 
panied by  severe  tenesmus.  The  treatment  consisted  in  absolute  rest  in  bed, 
astringent  diet,  hot  poultices  over  the  sigmoid  flexure,  and  rectal  irrigations 
with  bismuth  mixtures  (bismuth,  J  ounce;  water,  1  litre). 

After  four  weeks  of  treatment  patient  showed  considerable  improvement ; 
had  one  to  two  well- formed  stools  daily;  painless  defecation,  and  much  dimin- 
ished sensitiveness  over  sigmoid. 

Case  II. — Mr.  S.,  of  W.,  thirty-tw^o  years  old.  In  February,  1896,  while  in 
India,  he  had  a  severe  attack  of  acute  dysentery,  which  slowly  improved  after 
about  four  weeks.  A  sensitive  area  remained,  however,  in  the  left  lower 
portion  of  the  abdomen.  Pain  was  particularly  evident  while  riding,  so  as  to 
necessitate  the  giving  up  of  that  exercise.  After  walking  about  for  several 
hours  the  patient  usually  felt  more  or  less  severe  pain  in  the  above-mentioned 
area.  Appetite  good.  Stools  always  show  a  tendency  to  diarrhoea.  Examina- 
tion reveals  circumscribed  sensitiveness  and  a  feeling  of  light  resistance  over 
the  sigmoid  flexure.     Everything  else  normal. 

These  cases  demonstrate  that  local  inflammation  of  the  sigmoid 
does  occur.  In  the  first  instance  the  etiology  was  very  probably 
an  infection  originating  in  the  recto-vaginal  fistula ;  the  second  case 
very  probably  originated  from  the  previous  dysentery. 

The  diagnosis  is  made  from  the  catarrh  of  the  large  bowel,  aixd 
from  the  sharply  defined  sensitive  area  corresponding  to  the  sigmoid 
flexure.  There  need  not  be  a  demonstrable  resistance.  Differen- 
tially, we  must,  in  the  first  place,  consider  malignant  neoplasms,  and 
then  diseases  of  the  female  adnexa.  By  careful  examination  we 
ought  to  be  able  to  exclude  both  groups  of  diseases. 

The  treatment  is  the  same  as  that  of  chronic  catarrh  of  the  large 
intestine. 

(c)  Exudative  Pericolitis  •  Primär?/  Submucous,  Circtimscriled 

Colitis  (Pal) 

Under  the  name  of  exudative  pericolitis.  Windscheid  '^^,  of  the 
Leipsic  Clinic,  first  described  a  condition  characterized  by  the  de- 
velopment of  acute  exudative  peritonitis  about  the  ascending  colon. 
This  affection  is  distinguished  from  typhlitis  and  appendicitis  in 
that  the  right  iliac  fossa  is  entirely  free,  and  from  tumour  by  the 
acute  onset  and  constant  fever.  In  the  same  year  Eisenlohr  ^^  re- 
ported "  a  case  of  abscess  behind  the  ascending  colon."     Since  this 


476  DISEASES   OF   THE   INTESTINES 

is  tlie  only  instance  in  which  an  autopsy  was  performed,  its  impor- 
tant points  are  here  briefly  recapitulated. 

A  ferryman,  thirty-one  years  old,  alcoholic,  with  cirrhosis  of  the  Hver,  on 
March  31st  became  ill  with  chills,  vomiting,  diarrhoea,  and  marked  abdominal 
distention.  On  examination,  the  right  hypochondrium  was  found  sensitive  to 
pressure,  and  painful  ;  pulse  frequent  ;  diarrhoea  ;  vomiting  bilious  but  not 
feculent  ;  urine  contains  no  albumin  ;  peptonuria  found  once. 

March  24th.  Fluctuation  in  the  abdomen  with  disappearance  of  perito- 
nitis ;  later,  ascites  ;  evening  temperature  39°  C. 

Death  on  May  29th.  Autopsy  showed  a  small  abscess  cavity  situated  be- 
low the  upper  portion  of  the  ascending  colon  and  between  the  hepatico-colic 
ligament,  the  anterior  surface  of  the  kidney  capsule,  and  the  descending  por- 
tion of  the  duodenum.  This  cavity  contained  a  scanty  amount  of  semisolid, 
inspissated,  yellowish  pus.  The  mass  measured  about  ten  centimetres  verti- 
cally, and  somewhat  less  horizontally.  Its  position  corresponded  to  the  mesen- 
tery of  the  upper  portion  of  the  ascending  colon.  The  walls  of  the  abscess 
cavity  were  tough,  and  thickened  by  connective  tissue  ;  the  peritoneum  of  the 
intestines,  particularly  that  of  the  caecum  and  appendix,  showed  no  trace  of 
previous  inflammation.  The  entire  mucous  membrane  presented  no  evidence 
of  previous  ulcers,  cicatrizations,  or  infiltrations.  The  abscess  was  entirely 
outside  of  the  intestinal  wall. 

In  1895  Fleiner''^  reported  a  case  which  he  also  described  as  a 
pericolitic  exudate.  J.  Pal'^*'  recently  published  a  series  of  such 
observations,  in  which  he  thoroughly  discusses  the  question.  Pal's 
cases  include  exudates  about  various  portions  of  the  large  intestine, 
five  cases  of  ascending  colitis,  one  of  colitis  of  the  left  or  both  flex- 
ures, one  of  colitis  of  the  right  flexure,  and  one  of  descending 
colitis.  He  considers  colitis  as  a  submucous  inflltration  which  is 
developed  from  peculiar  changes  in  the  intestinal  contents,  and 
which  either  suppurates  and  ruptures  or  is  absorbed. 

I  also  am  in  a  position  to  report  a  case  of  this  kind  which,  after 
laparotomy,  came  to  the  autopsy  table. 

H.  K.,  nineteen  years  old,  student.  As  a  child  suffered  from  pertussis 
and  frequent  pulmonary  and  intestinal  catarrhs.  In  1889  tubercular  knee  and 
hip-joint  disease,  cured  by  extension  and  iodoform  injections.  After  the 
chloroform  narcosis  then  necessary,  for  the  first  time  there  developed  vomiting, 
with  colicky  pains  and  marked  sensitiveness  in  the  left  side  of  the  abdomen. 
Cure  after  eight  days.  Then  absolutely  well  for  six  years.  On'  March  22d, 
1397,  another  attack  after  drinking  cold  beer.  Severe  pain  in  the  umbilical 
region,  marked  vomiting,  and  constipation.  These  attacks  were  repeated  five 
times  in  four  weeks,  each  time  lasting  one  to  tliree  days.  The  last  attack  be- 
gan April  20,  1897,  with  severe  colicky  pains  to  the  left  of  the  umbilicus,  and 
radiating  to  the  back.  Vomiting  and  constipation  ;  no  fever  (?).  "When  seen 
in  consultation  (April  23d),  to  the  left  of  the  umbilicus  there  was  felt  an  in- 


TYPHLITIS,   PERITYPHLITIS   (APPENDICITIS)  477 

tensely  painful,  incompressible  resistance  the  size  of  an  apple.  Since  the 
attendant  physician  has  given  the  patient  laxatives  and  irrigations,  faecal 
tumour  can  be  absolutely  excluded.  Neoplasms  also,  because  of  the  intense 
sensitiveness.  The  diagnosis  of  serous  exudative  pericolitis  was  therefore 
made. 

Treatment. — Rest  in  bed,  ice  bag,  opium  pei'  Tectum.,  fluid  diet.  First 
stool  four  days  after  these  regulations.  Resistance  can  still  be  felt.  Four 
days  later,  tumour  can  no  longer  be  felt.  May  5,  1897,  tumour  had  entirely 
disappeared  ;  no  sensitiveness  in  the  area  above  mentioned.  General  condition 
good.  Course  of  waters  at  Kissingen  in  the  summer  of  1897  followed  by 
favourable  results.  In  autumn,  1898,  new  attacks  at  intervals  of  three  to  four 
weeks  ;  at  the  last  attack  (end  of  October)  there  was  absolute  retention  of 
stool  and  flatus.  On  October  31st,  laparotomy  performed  by  Professor  Riedel, 
of  Jena.     The  following  facts  are  borrowed  from  his  report  of  the  case : 

Incision  shows  the  transverse  colon  moderately  distended  by  gas  ;  isolated 
white  patches  in  the  mesentery«  To  the  left  and  above  the  cicatrized  omentum 
is  adherent  to  the  tip  of  the  spleen,  which  is  very  movable.  The  splenic  flexure 
is  extremely  coiled,  the  individual  coils  being  connected  to  one  another  by 
glistening,  white,  cicatricial  tissue.  Loosening  of  the  mesenteric  adhesions. 
Ether  bronchitis  ;  death  from  diffuse  peritonitis. 

In  mj  opinion,  these  numerous  scar  tissue  adhesions  were  the 
remnants  of  many  previous  attacks  of  exudative  peritonitis. 

Despite  the  small  number  of  cases  which  have  been  observed, 
there  is  no  doubt  that,  clinically,  there  do  occur  serous  or  purulent 
exudates  without  involvement  of  the  appendix.  Their  etiology  is 
difficult  to  determine.  The  explanation  given  by  Pal  is  founded 
upon  a  case  of  Eisenlohr's,  but  since  the  entrance  point  for  the  de- 
velopment of  the  abscess  is  unknown,  this  case  must  be  used  only 
with  the  m-eatest  caution  for  the  establishment  of  a  new  disease. 


to" 


Symptomatology  and  Diagnosis 

According  to  Pal's  description,  the  onset  is  sudden,  with  symp- 
toms of  inflammatory  swelling  of  the  large  intestine,  accompanied 
by  fever,  nausea,  or  vomiting  ;  there  soon  develops  a  sensitive  area, 
painful  to  pressure,  and,  in  a  few  days,  a  palpable  resistance.  The 
resistance  may  rapidly  increase  in  extent ;  at  this  stage  the  tumour 
is  quite  sensitive  to  pressure.  When  fever  subsides  the  sensitiveness 
also  disappears.  The  rest  of  the  abdomen  is  slightly  or  not  at  all 
affected  by  the  process. 

The  most  frequent  site  of  the  disease  is  the  hepatic,  less  fre- 
quently the  splenic  flexure.  The  process  may  develop  in  other  seg- 
ments of  the  large  intestine,  particularly  in  the  ascending  colon. 
When  affectino;  the  descendino;  colon  or  the  sigmoid  flexure,  the 


478  DISEASES  OF   THE  INTESTINES 

clinical  picture  is  tlie  same  as  that  of  sigmoiditis  (Mayor).  Occa- 
sionally, several  intestinal  segments  may  be  simultaneously  in- 
volved. In  the  beginning  the  clinical  picture  may  impress  one  as 
that  of  a  circumscribed  peritonitis,  but  the  rapidly  developing  cylin- 
drical area  of  resistance  points  directly  to  the  intestines  as  the  origin 
of  the  lesion. 

The  fever  is  generally  of  short  duration  and  may  be  overlooked, 
but  when  suppuration  supervenes  it  may  become  quite  marked.  In 
the  beginning  the  bowels  may  be  normal  or  constipated.  Fre- 
quently there  is  an  accumulation  of  gas.  There  is  often  marked  in- 
dicanuria. 

DrFFEEENTIAL    DIAGNOSIS 

Differentiation  from  typhlitis  and  perityphlitis  is  the  first  con- 
sideration, particularly  when  the  process  is  localized  on  the  right 
side  in  the  neighbourhood  of  the  c^cura.  Pal  places  a  certain  value 
on  palpation  and  percussion  for  the  separation  of  the  cascum  from 
the  diseased  colon.  He,  however,  seems  to  undervalue  the  dif- 
ficulties of  an  exact  differential  diagnosis  of  this  disease  from  peri- 
typhlitis. When  we  consider  the  numerous  variations  in  position 
of  the  csecum,  and  the  different  localities  of  perityphlitic  abscesses 
and  exudates,  error  would  appear  unavoidable.  When  the  colitis  is 
situated  in  the  vicinity  of  the  right  hypochondrium,  cholelithiasis 
may  have  to  be  considered,  and,  under  complicating  conditions,  the 
diagnosis  may  be  very  difficult.  Perigastritis  and  perinephritis 
may  also  come  into  question. 

Tkeatment 

In  general  the  treatment  embodies  the  usual  principles  employed 
in  all  inflammatory  processes  of  the  intestine — rest  in  bed,  ice,  in- 
testinal irrigations,  and  opiates  when  the  pain  is  very  severe.  Dur- 
ing the  first  few  days  fever  diet  should  be  given  ;  in  the  follomng 
days  the  diet  is  that  of  appendicitis  after  the  acute  inflammatory 
s^nnptoms  have  disappeared  (see  page  154).  After  the  exudate  has 
fully  developed  and  acute  symptoms  have  diminished,  warm  appli- 
cations are  in  place.  Pal  particularly  recommends  hot  flaxseed 
poultices.  We  may  later  attempt  to  aid  absorption  of  the  remain- 
der of  the  exudate  by  massage,  and  iodin  and  mercurial  oint- 
ments. When  a  fluctuating  abscess  develops,  incision  should  not 
be  delaved. 


TYPHLITIS,   PERITYPHLITIS  (APPENDICITIS)  479 

Repeated  attacks  of  pericolitis  or  signs  of  chronic  adhesive,  in- 
testinal inflammation  maj  require  surgical  treatment,  but  at  present 
the  success  of  such  operations  is  doubtful. 


LITERATURE 

1.  Sahli.     Verhaodl.  des  XIII.  Congresses  f.  innere  Medicin,  Wiesbaden,  1895. 

2.  Harley.     St.  Thomas  Hosp.  Rep.,  vol.  xi,  p.  128,  1881. 

3.  Mariage.     Contribution  ä  I'etude  de  I'intervention  chirurgicale  dans  les  in- 

flammations pericoecales,  These  de  Paris,  1891. 

4.  Curschmann.     Verhandl.   des  XIII.    Congresses  f.   innere  Medicin,  Wies- 

baden, 1895,  S.  291. 

5.  Lennander.     Ueber  Appendicitis,  Wien  u.  Leipzig,  1895.     (Cases  70  and 

71) ;  of.  also  Volkmann's  Samml.  klin.  Vorträge,  1893,  No.  175. 

6.  Porter.     Medical  News,  p.  209,  1895. 

7.  Krönlein.     Vereinigung  Schweizer  Aertzte,  1893. 

8.  Manley.     Cited  by  Borchardt,  Grenzgebiete,  1897,  Bd.  ii,  S.  310. 

9.  Meusser.     Ibid.,  Bd.  ii,  H.  3  u.  4. 

10.  Borchardt.     Ibid.,  Bd.  ii,  S.  312. 

11.  Ribbert.     Virchow's  Archiv,  Bd.  cxxxii,  1893. 

12.  Maurin.     These  de  Paris,  1890. 

13.  Bryant.     Cited  by  Fowler,  Ueber  Appendicitis,  Berlin,  1896. 

14.  F.  von  Sydow.     Cited  by  Lennander,  Ueber  Appendicitis,   p.   17.      (See 

ref.  5.) 

15.  Krausshold.     Volkmann's  Samml.  klin.  Vorträge,  No.  191,  1881. 

16.  Renvers.     Deutsche  med.  Wochenschr.,  1891,  S.  177. 

17.  Treves.     Perityphlitis  and  its  Varieties,  London,  1897,  p.  9. 

18.  Murphy.     Cited  by  Treves,  loc.  cit. 

19.  Tavel  u.  Lanz.     Ueber  die  Aetiologie  der  Peritonitis,  Basel,  1893. 

20.  Eckehorn.     Upsala  Lackareforen,  Foerhandlingar,  1893. 

21.  Morris.     Centralblatt  für  Chirurgie,  1895,  S.  609. 

22.  Karewski.     Deutsche  med.  Wochenschr.,  1897,  Nos.  19-21. 

23.  Nothnagel.     Darmkrankungen,  S.  639. 

24.  Steiner.     Zur  pathologischen  Anatomie  des  Wurmfortsatzes,  Basel,  1892. 

25.  Zuckerkandl.     Ueber  die  Obliteration  des  Wurmfortzsatzes  beim  Menschen, 

Wiesbaden,  1894. 

26.  Talamon.     MMecine  moderne,  1896,  No.  9. 

27.  Coley.     New  York  Med.  Rec,  Feb.  15,  1896. 

28.  Small.     Ibid.,  Sept.  10,  1898. 

29.  Golubeff.     Berl.  klin.  Wochenschr.,  1897,  No.  1. 

30.  Penzoldt.     Penzoldt-Stintzing's  Handbuch,  Bd.  iv,  S.  666. 

31.  Sonnenburg.     Pathologie  u.  Therapie  d.  Perityphlitis,  2te  Auflage,  Leip- 

zig, 1897. 

32.  Rotter.     Ueber  Perityphlitis,  Berlin,  1897. 

33.  Kümmell.     Ueber  Perityphlitis,  Leipzig,  1896. 

34.  Fowler.     Ueber  Appendicitis,  Berlin,  1896,  S.  68.     [A  Treatise  on  Appen- 

dicitis, Philadelphia,  1901.] 


480  DISEASES  OF  THE  INTESTINES 

35.  Edebohls.     Amer.  Journal  of  the  Med.  Sciences,  May,  1894. 

36.  Richardson.     Ibid.,  January,  1894. 
87.  Naumann.     Hygeia,  1891. 

38.  Mannaberg.     Centralbl.  f.  innere  Medicin,  1894,  No.  10. 

39.  von  Hochstätter.     Beiträge  zur  Chirurgie,  Eestschrift  für  Billroth.     Cited 

by  Nothnagel,  Darmkrankheiten. 

40.  Caspersohn.     Münch.med.  Wochenschr. ,  1893,  No.  43. 

41.  Goldbach.     Prager  med.  Wochenschr.,  1898,  No.  16. 

42.  A.  Pick.     Vorlesungen  über  Magen-  u.  Darmkrankheiten,  Leipzig  u.  Wien, 

1897,  S.  58. 

43.  Monod  et  Vanvers.     L'Appendicite,  p.  83. 

44.  Bull.     New  York  Med.  Rec,  1894,  vol.  ii,  p.  30. 

45.  Naunyn.     Klinik  der  Cholelithiasis,  Leipzig,  1893,  S.  8G. 

46.  Curschmann.     Deutsches  Arch,  für  klin.  Medicin,  Bd.  liii,  H.  1  u.  3. 

47.  Sonnenburg.     Deutsche  med.  Wochenschr.,  1897,  No.  40. 

48.  Sheild.     Internat.  Magazine,  January,  1895. 

49.  Heubuer.     Congress  f.  innere  Medicin,  München,  1895. 

50.  Rendu.     Gaz.  des  Hopitaux,  1897,  No.  40. 

51.  Nothnagel.     Wiener  klin.  Wochenschr.,  1899,  No.  15. 

53.  Ewald.      XXVIII.    Congress   d.    deutschen  Gesellsch.  f.   Chirurgie,   1899; 
Berl.  klin.  Wochenschr.,  1899,  No.  34. 

53.  A.  Fraenkel.     Deutsche  med.  Wochenschr.,  1891,  No.  4. 

54.  WoUberecht.     Inaug.-Diss.,   Berlin,    1891  ;    Conrad,   Inaug.-Diss.,    Berlin, 

1898  ;  Croizet,  These  de  Lyon,  1893. 

55.  Gendron.     These  de  Paris,  1885. 

56.  Terrillon.     Cited  by  Fowler  (see  ref.  34). 

57.  Bull  and  Fowler.     Cited  by  Sonnenburg  (see  ref.  31), 

58.  Nothnagel.     Darmkrankheiten,  S.  699. 

59.  E,  Fränkel.     Volkmann's   Samml.  klin.  Vorträge,  1898,  No.  339.      (Here 

will  be  found  complete  literature.) 

60.  Ewald,     von  Leyden's  Handb.  der  Ernährungstherapie,  1808.  Bd.  ii.  S.  366. 

61.  Ferrand.     Cited  by  Grohe,  p.  100. 

63.  Schede.     Deutsche  med.  Wochenschr.,  1893,  S.  523. 

63.  Mikulicz.     Grenzgebiete,  1898,  Bd.  iii,  H.  1,  S.  163. 

64.  Gerhardt.     Ibid.,  Bd.  i,  H.  3,  S.  354. 

65.  Wieland.     Mittheil,  aus  Kliniken  u.  medicin.  Instituten  d.  Schweiz,  1895, 

Bd.  i,  H.  7. 

66.  P.  Grawitz.     Charite-Annalen,  1886,  Bd.  xi. 

67.  Sonnenburg.     Grenzgebiete,  1898,  Bd.  iii,  p.  1. 

68.  Kümmell.     Berl.  klin.  Wochenschr.,  1898,  No.  15. 

69.  A.  Mayor.     Revue  m6dic.  de  la  Suisse  Romande,  1893,  No.  7,  p.  431. 

70.  Galliard.     Traite  de  medecine  (Brouardel-Gilbert),    T.  iv,  .p.   603,    1897. 

Gaz.  des  Hopitaux,  1897,  No.  7. 

71.  von  Leube.     Specielle  Diagnose  d.   inneren  Krankheiten,    Leipzig,   1889, 

S.  381. 
73.  Rosenheim.     Pathologie  u.   TherajDie    d.    Krankheiten    des   Darms,    1893, 

S.  457. 
73.  Windscheid.     Deutsches  Arch.  f.  klin.  Medicin,  1889,  Bd.  xlv,  S.  333. 


TYPHLITIS,    PERITYPHLITIS  (APPENDICITIS)  481 

74.  Eisenlohr.     Deutsche  med.  Wochenschr.,  1890,  No.  44. 

75.  Fleiner.     Miincli.  med.  Wochenschr.,  1895,  No.  42  et  seq. 

76.  J.  Pal.     Wiener  klin.  Wochenschr.,  1897,  No.  18  u.  19. 

[77.  Hartley,   F.     Dennis's  System  of  Surgery,  Philadelphia,   1896,  vol.   iv, 

p.  385,  etc.] 
[78.  Kraft,  C.     Revue  med.  de  la  Suisse  rom.,  Geneve,  1893,  T.  xiii,  p.  764. J 
[79.  McCosh  and  Hawkes.     Amer.  Jour,  of  the  Med.   Sciences,  1897,  vol.  ii, 

p.  885.] 
[80.  Johnson,  M.  M.     Jour,  of  the  Amer.  Med.  Assoc,    1896,   vol.   xxvi,  p. 

1203.] 
[81.  Gerster,  A.  G.     New  York  Med.  Jour.,  1890,  vol.  liii,  pp.  6-14.] 
[82.  Bayley,  N.  B.     New  York  Med.  Rec,  1895,  vol.  xlvii,  p.  342. J 
[83.  Deaver,  J.  B.    A  Treatise  on  Appendicitis,  Philadelphia,  1900,  p.  246,  etc.] 
[84.  Morton,  T.  G.     Jour,  of  the  Amer.  Med.  Assoc,  1888,  p.  733.] 
[85.  McBurney,    Charles.     Dennis's    System  of    Surgery,  Philadelphia,  1896, 

vol.  iv,  p.  415,  etc.] 
[86.  Bull,  W.  T.     Annals  of  Surgery,  1896,  p.  764.] 
[87.   Senn,  N.     Jour,  of  the  Amer.  Med.  Assoc,  March  6,  1896.] 
[88.  Murphy,  J.  B.     Medical  News,  January,  1895.] 
[89.  Mynter,  H.     Appendicitis  and  its  Surgical  Treatment,  Philadelphia,  1897, 

p.  143.] 
[90.  Fenger,  C.     Amer.  Jour,  of  Obstetr.,  1893,  vol.  xxviii,  No.  2.] 
[91.  Fitz,  R.  H.     Amer.  Jour,  of  the  Med.  Sciences,  1886,  pp.  321-846.] 
[92.   Sands,  H.  B.     New  York  Med.  Jour.,  1888,  vol.  xlvii,  pp.  197-205  and 

607.] 
[93.  McBurney,  Charles.     Ibid.,  1888,  vol.  xlvii,  p.  719.] 
[94.  Weir,  R.  F.     New  York  Med.  Rec,  1889,  vol.  xxxv,  p.  449.] 
[95.  Anders,  J.  M.     Text-Book  of  the  Practice  of  Medicine,   Philadelphia, 

1900,  fourth  edition,  p.  812.] 
[96.  Lockwood,  G.  R.     Manual  of  the  Practice  of  Medicine,  Philadelphia, 

1896,  p.  514.] 
[97.  Pepper,  W.     American  Text-Book  of  the  Theory  and  Practice  of  Medi- 
cine, Philadelphia,  1894,  vol.  ii,  p.  823.] 
[98.  Osier,  W.     The  Principles  and  Practice  of  Medicine,  New  York,  1898, 

third  edition,  p.  530.] 
[99.   Stein,  R.     Erfahrungen  über  Appendicitis.     Deutsche  med.  Wochenschr., 

1899,  No.  27,  S.  442.] 
[100.  Wiener,  J.     New  York  Med.  Rec,  May  19,  1900.] 
[101.  Einhorn,  M.     Diseases  of  the  Intestines,  New  York,  1900,  p.  220.] 
[102.  Deaver,  J.  B.     Annals  of  Surgery,  1897,  p.  325.] 
[108.  Tiffany,  L.  McL.     Reference  Handbook  of  the  Medical  Sciences,  1900, 

vol.  i,  p.  428.] 
[104.  McNutt,  W.  F.     Amer.  Syst.  of  Pract.  Medicine,  New  York  and  Phila- 
delphia, 1898,  vol.  iii,  p.  311.] 
[105.  Tyson,  J.     The  Practice  of  Medicine,  Philadelphia,  1900,  p.  404.] 
[106.  McBurney,  C.     New  York  Med.  Jour.,  1889,  pp.  676-684.] 
[107.  Lloyd,  S.     New  York  Med.  Rec,  Feb.  10,  1900,  p.  228.] 
[108,  Meyer,  W.     Ibid.,  Feb.  29,  1896.] 


CHAPTER  XX 

DISEASES   OF  THE  RECTUM'' 

1.  Proctitis 

Peoctitis  is  an  inflammation  of  the  mucous  membrane  of  the 
rectum.  It  maj  be  acute  or  chronic,  circumscribed  or  diffuse,  pri- 
mary or  secondary.  Its  causes  are  but  little  understood.  Undoubt- 
edly catarrh  of  the  rectum  may  be  caused  by  entozoa,  particularly 
parasites  of  the  large  intestine  (especially  oxyuris  vermicularis). 
The  theory  of  an  infectious  proctitis  in  pruritus  ani,  hemorrhoids, 
foreign  bodies,  neoplasms,  prolapsus  ani,  mechanical  irritation,  etc., 
is  very  plausible.  The  view  constantly  expressed,  even  in  the  most 
recent  text-books  and  monographs,  that  there  exists  a  connection 
between  proctitis  and  the  abuse  of  drastic  purgatives,  does  not  seem 
sufiiciently  proved.  Among  numerous  observations^  I  have  found 
but  one  instance  of  this  kind.  It  is  doubtful  whether  cooling  of  the 
pelvic  region  may  produce  proctitis. 

The  most  frequent  cause  of  primary  proctitis  is  best  sought  for  in 
the  composition  and  character  of  the  evacuations  themselves.  These 
may  both  chemically  and  mechanically,  and  under  certain  circum- 
stances also  bacteriologically,  produce  acute  or  chronic  catarrh  of 
the  rectum.  The  most  frequent  causes  of  secondary  proctitis  are 
foreign  bodies  (fruit  seeds,  meat  bones,  fish  bones,  etc.),  ulcerations, 
neoplasms,  hemorrhoids  (so-called  mucous  hemorrhoids),  prolapsus 
ani,  and  rectal  flstulee.  Infectious  diseases  (gonorrhoea,  diphtheria, 
dysentery)  are  also  looked  upon  as  etiological  factors. 

As  shown  by  recent  investigations,  gonorrhoeal  proctitis  may 
occur  both  in  men  and  women.  In  men  it  results  only  from 
sodomy.     In  women  it  is  very  frequently  due  to  the  carrying  over 

*  The  scope  of  this  work  only  allows  of  a  description  of  those  rectal  diseases 
which  are  particularly  interesting  to  the  medical  practitioner.  Malformations  of 
the  rectnm,  wounds,  and  foreign  bodies  will  therefore  not  be  discussed.  Rectal 
cancer  is  found  in  the  chapter  on  Intestinal  Cancer  (page  318) ;  the  neuroses  of 
the  rectum  are  found  among  the  Intestinal  Neuroses. 
483 


DISBASES  OF  THE  RECTUM  483 

of  gonorrhoeal  secretions  to  the  anal  region,  and,  more  rarely,  to 
extension  of  inflammation  from  the  Bartholinian  glands,  recto- 
vaginal fistulse,  etc.  Jullien^  and.  Baer^  have  recently  investigated 
the  existence  and.  nature  of  rectal  gonorrhoea.  The  latter  investi- 
gator found  this  disease  in  thirty-eight  per  cent  of  all  women 
infected  with  gonorrhcea,  though  rarely  with  any  subjective  symp- 
toms. Gonococci  are  constantly  found  in  these  cases.  Proctitis 
occurs  frequently  in  women  with  extreme  uterine  displacements. 
Disease  of  the  bladder  and  prostate  may  also  produce  proctitis. 
Buche  ^  states  that  gout  may  also  cause  proctitis,  but  the  connec- 
tion between  these  two  diseases  has  not  been  proved. 

Symptomatology  and  Diagnosis 

The  symptoms  of  proctitis  vary  with  the  severity  and  extent  of 
the  process.  In  acute  cases  the  inflammatory  symptoms  predomi- 
nate ;  in  the  milder  ones  there  is  a  feeling  of  fulness  and  pressure 
in  the  rectum.  When  the  inflammation  is  severe  the  patients  may 
complain  of  marked  boring  pain,  accompanied  by  annoying  tenes- 
mus. The  pain  may  be  limited  to  the  rectum,  or  may  radiate 
toward  the  back,  external  genitals,  bladder,  and  lower  extremities. 
The  movements  are  generally  voluntarily  repressed,  and  every 
effort  at  evacuation  produces  spasm  of  the  sphincter  and  levator 
ani.  If,  after  continued  tenesmus,  the  patient  finally  has  an  evacu- 
ation, the  latter  is  always  small  and  is  scarcely  ever  purely  fecu- 
lent, but  is  mainly  bloody  and  muco-purulent. 

In  the  severest  cases  the  general  health  is  usually  involved. 
The  pain  keeps  the  patients  in  bed,  appetite  and  sleep  are  markedly 
diminished,  and  from  the  very  beginning  fever  is  generally  present. 
The  finger  introduced  into  the  rectum  feels  the  contracted  sphinc- 
ter, which  allows  further  introduction  only  after  very  careful  and 
gradual  dilatation.  The  mucous  membrane  feels  hot,  oedematous, 
and  swollen.  Even  when  most  carefully  performed,  digital  explora- 
tion is  very  painful.  On  withdrawal,  the  finger  is  generally  found 
smeared  with  blood  or  blood  mixed  with  pus. 

In  cTironic  proctitis  the  symptoms  are  much  less  characteristic. 
There  is  a  feeling  of  straining  and  pressure,  which  in  the  presence 
of  impacted  fseces  may  amount  to  tenesmus.  Digital  examination 
is  less  annoying  to  the  patient.  The  mucous  membrane  feels  swol- 
len, soft,  and  velvety ;  it  bleeds  easily,  and  occasionally  secretes  pus. 
Sometimes  the  swollen  solitary  follicles  may  be  felt  as  prominences 
the  size  of  millet  seeds.     Defecation  may  be  painful.     The  stools 


484  DISBASES   OF   THE   INTESTINES 

are  often  mixed  with  blood  or  bloody  mucus  ;  in  isolated  cases  (e.  g., 
rectal  gonorrhoea)  thej  may  consist  entirely  of  pus.  In  acute  as 
well  as  in  chronic  proctitis,  a  paralysis  of  the  sphincter  may  result 
from  the  marked  and  deep  infiltration  of  the  inflammatory  process, 
60  that  there  is  a  continual  discharge  of  bloody  pus  or  muco-pus. 

Where  the  symptoms  are  well  defined,  the  diagnosis  of  acute 
proctitis  is  usually  easy  and  may  generally  be  made  without  digital 
examination.  For  the  diagnosis  of  the  etiology  digital  exploration 
is  necessary.  It  should  be  performed  with  the  greatest  caution- 
A  very  thin  suppository  of  opium  and  cocain  or  eucain  should  be 
previously  introdnced.  In  place  of  this  we  may  employ  a  collaps- 
able tin  tube  to  which  a  short  piece  of  rubber  tubing  is  attached. 
The  latter  is  well  oiled  and  passed  into  the  rectum.  The  collaps- 
able tube  is  then  slowly  squeezed  and  some  of  the  ointment  thus 
directly  introduced  into  the  rectum.  The  introduction  of  a  specu- 
lum, especially  without  narcosis,  is  an  unnecessary  procedure. 
Fever,  tenesmus,  and  bloody,  mucoid,  or  purulent  defecations  with 
very  little  faecal  matter  are  also  of  diagnostic  importance. 

The  diagnosis  of  chronic  proctitis  is  best  made  by  digital  and 
speculum  examination.  Thus  foreign  bodies  producing  this  affec- 
tion can  scarcely  escape  discovery.  Under  certain  circumstances 
the  diagnosis  of  the  nature  of  the  process  may  be  very  difficult. 
If  ulcerations  are  present,  we  must  consider  especially  the  tuber- 
cular, syphilitic,  gonorrhoeal,  and  stercoral  ulcers.  These  must  be 
differentiated  by  clinical  and,  more  particularly,  by  bacteriological 
examination  (gonococci,  tubercle  bacilli). 

If  no  sufficient  explanation  for  the  occurrence  of  the  disease  is 
found  in  the  rectum  itself,  the  etiology  must  be  sought  for  by 
examination  of  the  remaining  pelvic  organs — in  men,  the  bladder ; 
in  women,  the  genitals. 

Teeatjment 

Depending  upon  circumstances,  the  treatment  of  acute  proctitis 
should  be  either  symptomatic  or  radical.  The  latter  plan  is  appli- 
cable when  foreign  bodies,  inspissated  faeces,  diseases  of  the  neigh- 
bouring organs,  etc.,  are  the  cause  of  the  proctitis.  Symptomatic 
treatment  must  take  into  account  those  basic  principles  which 
apply  to  acute  inflammations  of  the  intestinal  mucous  membrane — 
above  all,  absolute  rest  and  immobilization  of  the  rectum.  The 
abdominal  or  lateral  posture  is  often  recommended  for  the  relief 
of  the  pain.     If  constipation  is  not  the  cause  of  the  lesion,  it  is 


DISEASES   OP   THE   RECTUM  485 

advisable  during  the  acute  inflammatory  stage  to  keep  the  bowels 
constipated  by  opiates,  given  either  per  mouth  or  rectum.  It  is  also 
necessary  to  decrease  the  amount  and  kind  of  the  nourishment  taken 
— an  easy  task  in  view  of  the  diminished  appetite  of  these  patients. 
When  the  inflammatory  symptoms  have  subsided  the  bowels  may  be 
moved  by  castor  oil  or  by  enemata  of  olive  oil.  After  this  expect- 
ant treatment  has  been  applied  for  eight  or  ten  days,  the  symptoms, 
in  the  vast  majority  of  cases,  disappear.  In  complicated  cases  the 
process  extends,  the  suppuration  spreads  to  the  periproctitic  tissues, 
and  a  periproctitis  results  (see  below). 

Tenderness  and  tenesmus  are  generally  well  controlled  by  the 
above-mentioned  narcotics.  Leeches  applied  in  the  neighbourhood 
of  the  anus  are  also  useful,  and  often  curative ;  their  action  is 
increased  by  warm  sitz  baths. 

Only  after  the  acute  symptoms  have  subsided  should  local  treat- 
ment be  begun,  if  at  all.  The  utmost  care  must  be  exercised  in  the 
choice  of  our  remedies.  The  most  appropriate  treatment  is  rectal 
irrigation  with  warm  decoctions  of  chamomile  or  linseed,  contain- 
ing a  few  drops  of  laudanum.  Where  there  is  copious  purulent 
secretion,  we  may  try  irrigations  with  very  dilute  sohitions  of 
nitrate  of  silver  (0.5  to  1  gram  in  1,000);  if  these  cause  severe 
reaction,  they  should  be  followed  by  an  irrigation  with  a  weak  salt 
solution. 

The  management  of  chronic  proctitis  differs  somewhat  from  the 
above.  The  first  and  leading  principle  is  the  recognition  and  treat- 
ment of  the  primary  disease.  Symptom atically,  we  must  regulate 
the  bowels,  and  keep  the  parts  as  clean  as  possible  through  copious 
rectal  irrigations.  It  is  immaterial  whether  for  this  latter  purpose 
(of  cleanliness)  we  use  permanent  rectal  drainage  with  the  apparatus 
proposed  by  Hofmokl  (with  which,  moreover,  there  seems  to  have 
been  no  extensive  experience),  or  the  usual  double-current  cathe- 
ters, or,  as  described  in  the  General  Division,  a  simple  catheter  with 
a  T  tube  similar  to  that  used  in  stomach  lavage.  According  to 
my  own  observations,  two,  or  at  most  three  irrigations  per  day  are 
sufläcient.  The  permanent  introduction  of  even  a  soft  instrument 
is  so  uncomfortable  that  patients  are  seldom  willing  to  undergo  this 
procedure. 

We  have  a  large  variety  of  antiseptics  and  astringents  to  choose 

from :  alum,  or  its  double  salt,  aceto-tartrate  of  aluminium  (2  to  3 

grams  per  1,000),  sulphate  and  sulpho-carbolate   of  zinc   (1  to  2 

grams  per  1,000),  tannic  acid  (3  to  5  grams  per  1,000),  nitrate   of 

33 


486  DISEASES   OP   THE   INTESTINES 

silver  (0.5  to  1  gram  per  1,000),  etc.  A  change  of  solutions  some- 
times seems  to  produce  a  more  rapid  cure. 

These  irrigations  are  undoubtedly  the  most  effectual  of  our 
therapeutic  measures ;  we  may,  however,  obtain  favourable  results 
with  suppositories  containing  the  above  astringents.  An  ointment 
syringe  has  been  recommended  for  the  same  purpose,  but  in  view 
of  the  application  of  ointments  by  the  collapsable  tin  tube  (see 
page  484),  which  has  given  me  the  most  satisfaction,  an  "oint- 
ment syringe  "  seems  superfluous.  We  may  in  a  measure  conduce 
to  cleanliness,  and  thus  indirectly  to  the  cure  of  the  disease,  by 
appropriate  medicated  sitz  baths  and  by  anal  douches.  In  England, 
internal  medication  vdth  balsam  of  copaiba,  extract  of  cubebs,  or 
oil  of  turpentine  is  highly  recommended.  I  have  not  found  it  suc- 
cessful in  my  cases.  The  use  of  sea  baths  and  other  balneothera- 
peutic measures  is  practised  by  balneologists ;  but  thus  far  no  con- 
vincing proofs  of  their  good  effects  have  been  adduced. 

Some  cases,  especially  resistant  ulcerative  and  gonorrhceal  proc- 
titis, are  extremely  obstinate  to  all  internal  therapeutic  measures. 

2.   Periproctitis 

This  is  an  inflammation  of  the  loose  cellular  tissue  about  the 
rectum.  Since  this  tissue  is  continuous  with  the  fatty  tissue  which 
fills  the  ischio-rectal  fossa  on  both  sides  of  the  termination  of  the 
rectum,  between  the  levator  ani  and  the  sacral  origin  of  the  gluteus 
maximus  muscles,  the  bulbous  urethra  and  the  perineal  fascia,  it  is 
evident  that  local  purulent  processes  may  spread  extensively.  The 
etiological  factors  are  the  same  as  those  already  described  under  proc- 
titis. Besides  these,  periproctitis  may  also,  though  now  very  rarely, 
occur  after  opei'ations  on  the  rectum  which  have  not  been  suffi- 
ciently aseptic.  Traumatism  is  also  regarded  as  a  cause  of  periproc- 
titis, particularly  since  Cruveilhier  has  described  a  very  marked  case 
of  this  kind,  resulting  from  a  "  fall  on  the  gluteus."  As  far  as  I 
can  learn,  modern  literature — which  certainly  contains  abundant 
cases  of  accidents — does  not  present  any  instance  similar  to  this. 

The  inflammatory  process  may  be  either  acute  or  chronic,  cir- 
'  cumscribed  or  diffuse,  the  acute  diffuse  type  being  the  most  fre- 
quent. 

From  the  seat  of  infection,  the  pus  burrows  through  the  cellu- 
lar interstices  and  extends  into  the  ischio-rectal  fossa.  The  perineal 
fascia  offers  a  slight  barrier  to  the  spread  of  the  process,  so  that  the 
anal  region  is  generally  affected  later  than  the  upper  rectal  seg- 


DISBASES   OF   THE  RECTUM  487 

ment,  about  whicli  the  pus  may  spread  freely  in  all  directions. 
Under  these  circumstances  the  abscess  may  rupture  either  exter- 
nally or  internally,  and  thus  produce  fistulse  {q.  v.). 

Symptomatology  and  Diagnosis 

The  symptoms  of  periproctitis  point  directly  to  the  seat  of  the 
lesion.  In  acute  periproctitis  the  most  persistent  subjective  symp- 
tom is  the  severe  pain,  and  a  feeling  of  fulness  and  tension  in  the 
anus  and  anal  region.  The  pain  becomes  unbearable  duriug  defe- 
cation, so  that  patients  voluntarily  retard  this  act  as  much  as  pos- 
sible. The  disease  generally  begins  with  a  marked  chill,  accom- 
panied by  high  fever.  When  the  process  is  very  extensive — an 
occurrence  occasionally  found  in  cases  improperly  treated — the  fever 
becomes  septic  in  character.  As  might  be  expected,  the  general 
health  soon  suffers  ;  the  patients  are  considerably  weakened  by  the 
fever,  anorexia,  and  loss  of  sleep,  and  present  the  picture  of  an 
acute  infectious  disease. 

The  objectwe  symptoms  are  usually  very  evident.  There  is 
a  more  or  less  hard,  reddened,  sensitive  infiltration  about  the  rec- 
tum. The  introduction  of  the  finger  causes  severe  pain,  and  re- 
veals a  hot,  swollen  mucous  membrane,  which  nai-rows  the  lumen 
of  the  rectum.  Bimanual  examination  elicits  fluctuation  relatively 
early.     In  women  a  vaginal  examination  may  also  be  made. 

In  chronic  cases  the  symptoms  are  less  defined.  The  abscess 
may  rupture  without  the  patient  even  knowing  of  the  existence  of 
a  periproctitis  or  proctitic  suppuration.  In  other  cases,  however, 
pain  during  defecation,  uncomfortable  sensations  in  the  rectal  re- 
gion, and  a  muco-purulent  or  bloody  discharge  indicate  the  char- 
acter and  seat  of  the  lesion. 

The  diagnosis  ought  present  no  difiiculty.  In  every  case  of 
periproctitis  digital  examination  of  the  rectum  should  be  made. 
In  this  manner  we  may  not  only  discover  the  cause  of  the  disease — 
e.  g.,  foreign  bodies — but  its  course  may  be  favourably  influenced. 
When  the  sensitiveness  is  very  marked  we  should  always  make  a 
digital  examination  in  the  manner  previously  described.  ]S"arcosis 
is  generally  unnecessary.  If  in  doubt,  we  may  wait  till  the  time 
of  operation,  when  the  whole  field  can  be  carefully  examined.  We 
have  already  pointed  out  the  importance  of  the  bimanual  examina- 
tion (best  in  the  knee-chest  position)  for  eliciting  fluctuation. 

The  diagnosis  of  chronic  periproctitis  is  attended  by  much  less 
pain  for  the  patient  than  the  acute.     A  speculum  may  be  employed. 


488 


DISEASES   OP   THE   INTESTINES 


As  in  proctitis,  so  here  also  it  may  be  difficult  to  establisli  the  cause 
of  the  affection  (ulcers,  fistulse).  In  the  section  on  Rectal  Ulcers 
we  shall  discuss  the  symptoms  of  diagnostic  importance. 

Treatment 

The  treatment  is  practically  surgical.  The  well-known  anti- 
phlogistic remedies  (ice  and  cold  applications  to  the  anal  region, 
leeches)  are  to  be  applied  only  in  the  beginning  of  the  affection — 
i.  e.,  until  the  first  signs  of  fluctuation  appear.  Pain  is  controlled 
by  injections  of  morphin,  better  by  opium  suppositories  (each  con- 
taining 0.03  gram  of  the  extract,  introduced  every  two  to  three 
hours),  or  by  opiates  given  internally  (tinct.  opii,  10  to  15  drops 
t.  i.  d.). 

When  fluctuation  is  present  the  abscess  should  be  opened  as 
soon  as  possible.  The  teehnic  of  this  procedure  is  to  be  found  in 
works  on  surgery. 

3.    Rectal  Fistulse 

Where  an  inflammatory  process  of  the  rectal  mucous  membrane 
ruptures  externally  and  produces  a  pervious  canal,  we  speak  of  it 

as  a  rectal  fistula.  This  is  the  so- 
called  complete  fistula.  Where  the 
canal  does  not  extend  through  to  the 
skin,  we  have  an  incomplete  inter- 
nal fistula.  Whei'e  periproctitic  and 
ischio -rectal  abscesses  perforate  ex- 
ternally, we  have  an  incomplete 
external  fistula.  The  accompanying 
illustrations  (Figs.  42,  43,  and  44),  taken  from  Esmarch's  excellent 
work  ^,  illustrate  these  conditions. 

The  causes  of  fistulse  are  similar  to  those  of  proctitis  and  peri- 
proctitis.    Ulcerations    or    abscesses   slowly   extend    through,   and 


Fig.    42. — Complete    Kectal    Fistula, 
(von  Esmarch.) 


Fig.  43. — Incomplete  Internal 
Eectal  Fistula. 


Fig.  44. — 1^ complete  External 
Eectal  Fistula. 


finally  perforate  the  different  layers  of  the  rectum.     The  process 
may  develop  very  acutely,  and  present  the  characteristic  features 


DISEASES  OP  THE  RECTUM  489 

of  purulent  proctitis  already  described,  or  it  may  be  very  slow  and, 
as  mentioned,  proceed  without  the  patient's  knowledge.  Accord- 
ing to  Allingham's  extensive  statistics,  a  large  percentage  of  fistulse 
(fourteen  per  cent)  are  tubercular.  It  is  very  important  for  the 
diagnosis  whether  the  fistula  occurs  in  persons  who  are  otherwise 
well  and  free  from  hereditary  taint,  or  whether  the  fistula  is  a 
complication  of  a  general,  especially  pulmonary,  tuberculosis.  For 
the  differential  diagnosis  and  for  purposes  of  treatment  a  careful 
general  examination  is  required. 

Symptomatology  and  Diagnosis 

If  symptoms  of  an  acute  proctitis  or  periproctitis  have  been 
present,  we  should  search  for  rectal  fistulse.  The  diagnosis  is  more 
difficult  when  the  fistula  develops  without  any  previous  symptoms. 
It  very  frequently  happens  that  patients  are  only  accidentally 
prompted  to  have  the  rectum  examined  after  the  disease  has  lasted 
a  long  while.  Some  discomfort,  or  a  feeling  of  slight  fulness 
in  the  rectal  region  before  or  after  defecation,  is  generally  all 
that  is  complained  of.  When  the  fistula  is  a  blind  one,  and  the 
secretions  cannot  escape,  these  symptoms  may  be  somewhat  in- 
creased in  severity.  There  is  a  sensation  of  heat  in  and  around 
the  rectum ;  the  patient  has  a  feeling  of  painful  tension,  or  even  of 
tenesmus. 

The  characteristic  objective  symptom  which  disquiets  the  patient 
is  the  discharge  of  greater  or  less  quantities  of  pus  from  the  exter- 
nal or  internal  fistulous  orifice.  The  pus  is  generally  thin  and 
serous,  and  is  rarely  mixed  with  blood  or  faeces.  The  discharge 
may  cause  an  annoying  intertrigo.  Patients  occasionally  declare 
that  they  pass  gas  through  the  fistula.  They  are  weakened  by 
the  continual  suppuration,  feel  tired,  dispirited,  and  unwilling 
to  work. 

In  simple  cases  the  diagnosis  is  easy;  in  complicated  cases  it 
may  be  so  difficult  that  the  kind  and  extent  of  the  fistulous  tract 
can  be  recognised  only  when  the  patient  is  under  general  ansesthesia. 
A  careful  examination  of  the  anal  region  and  rectum  should  be 
made.  The  external  orifice  of  the  fistula  may  be  variously  situated. 
It  is  D-enerally  in  the  direct  vicinity  of  the  anus,  but  may  be  at  quite 
some  distance  therefrom — e.  g.,  at  the  perinseum  or  the  gluteal  promi- 
nence. We  occasionally  meet  with  several  fistulse ;  in  fact,  the 
whole  region  of  the  anus  may  be  perforated  by  numerous  orifices. 
The  blind  external  orifice  may  present  a  pouting  mouth  filled  with 


490  DISEASES  OF   THE   INTESTINES 

granulations,  or  it  may  be  a  small,  barely  visible  furrow  bidden 
between  tbe  anal  folds,  and  scarcely  admitting  a  small  probe.  The 
internal  opening  is  I'ecognised  by  its  small  indurated  prominence, 
or  there  may  be  only  a  feeling  of  diffuse  infiltration,  or  no  appreci- 
able chanp-e  in  the  mucous  membrane.  In  rare  cases  there  is  an 
ulceration  at  the  internal  orifice  of  the  fistulous  tract.  Complete 
fistulse  are  recognised  by  passing  probes  through  the  fistulous  canal, 
thus  disclosing  both  its  orifices.  The  best  probe  for  this  purpose  is 
the  flexible  one  of  zinc  recommended  by  Esmarch ;  this  is  gently 
pushed  forward,  without  the  use  of  any  force.  Quenu  and  Hart- 
mann* recommend  thin,  soft  bougies,  like  those  used  in  urethral 
catheterization.  The  left  forefinger  is  introduced  into  the  rectum, 
so  that  it  may  follow  the  direction  of  the  instrument,  and  thus  dis- 
cover a  possible  internal  opening. 

If  this  does  not  succeed  there  may  still  be  a  complete  fistula,  for 
the  probe  may  have  followed  a  false  passage.  In  such  cases  a 
speculum  is  introduced  and  a  good  light  thrown  into  the  rectum, 
and  milk  or  a  carmine  or  eosin  solution  is  injected  into  the  external 
orifice  of  the  fistula.  In  this  connection  it  is  of  practical  importance 
to  know  that  the  internal  orifice  is  usually  either  in  the  region  of 
the  sphincter  or  directly  above  it,  and  that  only  very  rarely  is  it 
higher  than  5  centimetres  above  the  anal  orifice  (von  Esmarch).  In 
this  manner,  we  may,  by  careful  and  perhaps  repeated  examinations, 
recognise  a  complete  fistula.  This  also  applies  to  the  incomplete 
external  fistulse.  The  diagnosis  of  an  incomplete  internal  fistula  is 
sometimes  much  more  diflicult.  The  finger  when  introduced  may 
encounter  a  small  indurated,  buttonlike  prominence,  which  can, 
however,  quite  easily  escape  palpation.  At  all  events,  where  other 
symptoms  indicate  fistula,  we  should  not  rest  until  a  satisfactory  ex- 
planation for  the  symptoms  has  been  found.  In  complicated  cases 
it  will  be  necessary  to  make  a  careful  examination  under  nai'cosis. 
The  diagnosis  of  rectal  fistula  alone  is  not  sufiScient.  As  already 
mentioned,  we  must  determine  its  nature.  We  should  search  par- 
ticularly for  luetic  and  tubercular  symptoms,  which  may  change 
both  prognosis  and  therapy. 

Treatment 

The  treatment  of  rectal  fistulse  is  now  purely  surgical.  In  pre- 
antiseptic  times,  when  operative  treatment  of  these  conditions  was 
a  dangerous  proceeding,  conservative  treatment  was  attempted. 
The  oldest  method,  known  even   to  Hippocrates  and  occasionally 


DISEASES  OF  THE   RECTUM  49 1 

used  to  this  day,  is  ligation  of  the  complete  or  artificially  completed 
fistula.  The  other  methods — scarification,  injections  of  iodin,  nitrate 
of  silver,  alum,  etc. — are  all  obsolete.  With  modern  asepsis  and 
antisepsis,  the  operation  for  fistula  has  lost  all  danger.  The  ad\dsa- 
bility  of  operation  is  doubtful  only  when  there  is  advanced  tubercu- 
losis, and  when  other  tuberculous  ulcerations  exist  in  the  rectum. 
In  these  cases,  despite  splitting  of  the  fistulous  tract,  the  process 
steadily  progresses.  The  same  caution  also  applies  to  carcinomatous 
fistulse.  In  both  these  latter  instances  we  shall  have  to  limit  our- 
■selves  to  symptomatic  treatment,  particularly  to  copious  irrigation 
of  the  diseased  rectum.  A  description  of  the  technic  of  the  oper- 
ation for  fistula  in  ano  does  not  belong  to  this  work. 

4.   Fissures  and  Spasm  of  the  Anus 

Small  tears  or  excoriations  at  the  border  of  the  anus  may  pro- 
duce painful  reflex  spasms  of  the  anal  muscles.  In  the  chapter  on 
Intestinal  I^euroses  we  shall  see  that  spastic  conditions  of  the  anus 
may  also  be  caused  by  hysteria,  neurasthenia,  or  diseases  of  the  cen- 
tral nervous  system.  Fissures  are  more  or  less  extensive,  generally 
oval  losses  of  substance,  which  are  usually  superficial,  but  Avhich 
may  also  aifect  the  deeper  muscular  tissues.  They  are  often  found 
at  the  posterior  commissure,  and  less  frequently  laterally,  anteriorly, 
or  in  the  interior  of  the  rectum.  After  having  lasted  a  long  time, 
they  increase  in  size,  become  indurated,  and  have  a  dirty  gray  base. 
Fissures  are  generally  idiopathic,  but  may  occasionally  be  pro- 
duced by  gonorrhcea,  syphilis,  tuberculosis,  hemorrhoids,  etc.  They 
occur  in  both  sexes,  more  often  in  women  than  in  men,  and  are 
not  infrequently  found  in  early  childhood. 

Habitual  constipation  predisposes  to  fissures,  particularly  when 
there  is  a  disproportion  between  the  calibre  of  the  faeces  and  the 
anal  opening.  A  soft,  irritable  skin  also  favours  their  development. 
These  conditions  are  more  often  present  in  women,  hence  the 
greater  frequency  of  fissures  among  the  latter.  According  to  von 
Esraarch,*  fissures  frequently  occur  in  women  who  suffer  from  ante- 
version  or  retroversion  of  the  uterus.  The  act  of  parturition,  dur- 
ing which  the  rectal  region  and  anus  are  enormously  stretched,  may 
easily  produce  fissures. 

*  Loc.  cit.,  p.  148. 


492  DISEASES   OP   THE   INTESTINES 

Symptomatology  and  Diagnosis 

Anal  spasm  is  recognised  by  tlie  paroxysmal  pains  which  accom- 
pany defecation.  The  patients  liken  them  to  that  of  a  red-hot  iron 
boring  through  the  anus.  The  pain  may  be  limited  to  the  anus,  or 
radiate  to  the  bladder,  the  external  genitals,  or  the  legs.  The  pa- 
tients try  to  suppress  defecation  and  the  passing  of  flatus,  so  that 
these  cases  sometimes  have  marked  abdominal  distention.  Rest 
relieves  the  pain ;  motion,  or  even  sitting  for  a  long  time,  may  in- 
crease it. 

The  fissure  can  be  discovered  by  careful  inspection  or  digital 
exploration  of  the  rectum.  Where  digital  examination  is  very  pain- 
ful, or  where  the  finger  can  with  difficulty  be  passed  through  the 
anal  orifice,  it  is  better  to  previously  relieve  sensitiveness  by  the 
introduction  of  a  thin  suppository  of  opium  and  cocain,  or  by 
Cocain  ointment  spread  over  the  rectal  mucous  membrane  with  the 
previously  mentioned  collapsable  tin  tube.  According  to  von  Es- 
march,  a  small  polypoid  tumour  or  an  edematous  fold  of  the  skin 
of  the  anus  is  often  found  at  the  external  extremity  of  the  fissure. 
The  fissure  becomes  visible  only  when  this  growth  or  fold  is  drawn 
aside.  I  can  recall  but  one  such  instance.  For  the  purpose  of 
more  thorough  examination,  surgeons  (von  Esmarch  and  others) 
advise  narcosis.  Personally  I  have  always  found  the  above-men- 
tioned methods  sufficient.  It  appears  to  me  that  narcosis  is  only 
indicated  in  those  rare  forms  in  which  the  fissure  is  situated  higher 
up.  It  is  of  diagnostic  importance  to  determine  whether  the  fissure 
is  idiopathic,  or  secondary  to  gonorrhoea,  lues,  tuberculosis,  or  hem- 
orrhoids. 

Treatment 

Prophylaxis  is  of  the  first  importance.  In  those  suffering  from 
habitual  constipation,  that  condition  must  be  treated  upon  the  prin- 
ciples already  enunciated  (see  chapter  on  Constipation).  The  tis- 
sues of  the  anal  and  rectal  regions  must  be  hardened  by  washing 
with  solutions  of  tannin  and  alum,  or  with  soaps  containing  these 
substances,  and  by  sitz  baths.  The  patients  must  avoid  severe  strain- 
ing durino;  defecation. 

When  a  fissure  has  been  discovered,  the  anal  region  must  as  far  as 
possible  be  immobilized  ;  the  patient  should  remain  in  bed  till  cured. 
A  second  preliminary  condition  to  recovery  is  the  artificial  preven- 
tion of  defecation  (see  page  157).     The  patients  are  put  upon  a  fluid 


DISEASES   OF   THE   RECTUM  493 

diet,  and  get  ten  drops  of  tincture  of  opium  three  times  daily.  Of 
late  I  have  returned  to  the  use  of  opium  suppositories.  If  the  fis- 
sure can  be  seen,  it  is  best  dusted  with  some  dry  powder  (e.  g.,  airol, 
Xeroform,  iodoform,  orthoform,  calomel,  etc.),  without  directly 
touching  the  fissure  with  the  fingers.  I  have  seen  more  harm  than 
good  from  washing  with  antiseptic  solutions. 

After  a  week  of  this  treatment  I  give  the  patients  a  large  dose 
of  castor  oil,  and  advise  them  to  attempt  to  pass  stool  only  when 
they  feel  that  the  faeces  have  become  thoroughly  softened.  Under 
all  circumstances  straining  must  be  avoided.  The  first  evacua- 
tion is  usually  painless.  Sometimes  the  entire  treatment  must  be 
repeated  a  second  or  even  a  third  time.  I  can  warmly  recommend 
this  method,  although  some  individuals  cannot  retain  their  stools 
for  a  week ;  in  these  treatment  is  generally  unsuccessful.  Of  12 
cases  of  fissure  whose  histories  I  possess,  6  recovered  within  eight 
to  ten  days,  2  were  cured  in  three  weeks,  2  in  four  weeks,  and 
only  2  had  to  be  operated,  I  believe  it  incorrect  to  regulate  the 
bowels  by  purgatives. 

Local  treatment  with  various  astringent,  cauterizing,  and  anses- 
thetic  agents  has  been  recomuiended.  The  most  frequently  used  is 
cauterization  with  the  pure  nitrate  of  silver,  or  with  a  ten-per-cent 
solution  of  the  same.     Allingham  ^  employs  the  following  : 

Calomel 0.25 

Pulv.  opii 0.10 

Ext.  bellad 0.10 

Ung.  sambuci 5,00 

m 

This  ointment  is  to  be  frequently  spread  over  the  entire  anal 
surface.  Yan  der  Willigen  ^,  and  recently  Conitzer ',  recommend 
pencilling  twice  daily  with  a  brush  dipped  in  pure  Ichthyol.  I  have 
twice  seen  good  results  from  this  method,  but  in  a  third  advanced 
case  of  fissure  it  was  useless.  Cases  which  are  not  cured  by  any  of 
the  above  methods  require  radical  treatment.  A  Ijloodless  method 
consists  in  stretching  and  massaging  the  anal  sphincter  under  narco- 
sis. This  procedure,  which  is  often  employed  in  France,  and  is  also  ^ 
highly  recommended  by  Allingham^  and  von  Esmarch  V^  i"fii*ely 
used  in  Germany.  The  most  certain  method  is  the  splitting  of  the 
fissure  with  a  knife  or  thermocautery  [Paquelin],  after  which  heal- 
ing is  usually  quite  rapid. 


494  DISEASES   OF   THE  INTESTINES 

5.    Ulcers  of  the  Rectum 

Ulcers  of  the  rectum  occur  under  the  most  varied  conditions — 
primary,  secondary,  Kmited  to  the  rectum,  or  involving  other  seg- 
ments of  the  large  intestine. 

Primary  rectal  ulcers  are  traumatic  (from  enemata  or  foreign 
bodies),  gonorrhoeal,  and  syphilitic  (both  from  sodomy).  Gonor- 
rhceal  and  syphilitic  ulcerations  may  also  develop  indirectly  (Bar- 
tholinitis, recto-vaginal  fistula,  breaking  down  of  large  condylomata, 
etc.).  Among  secondary  ulcerations  are  the  tubercular,  which  always 
result  from  auto-infection.  Finally,  there  are  the  dysenteric  and 
follicular  ulcers,  which  also  occur  higlier  up  in  the  intestines.  These 
various  types  require  a  brief  individual  description. 

1.  Dysenteric  ulcers  result  from  chronic  dysentery,  ulcerative 
destruction  of  the  rectal  mucous  membrane,  or  from  a  follicular 
catarrh.  By  destruction  of  the  follicles  and  confluence  of  the 
destroyed  areas  there  gi-adually  develop  deep  and  extensive  ulcera- 
tions. The  rectal  lesion  is  always  secondary  to  involvement  of 
other  portions  of  the  large  intestines.  The  ulcers  may  extend  into 
the  serous  coat,  and  produce  perforative  peritonitis,  abscess,  and 
fistula,  or  subsequent  cicatricial  stenosis. 

2.  Follicular  ulcers  develop  in  the  rectum  and  large  bowel 
where  there  is  catarrh  with  marked  swelling  of  the  follicles.  When 
these  follicles  rupture,  a  small  flat  ulcer  results.  Several  such 
ulcers  coalesce  and  produce  larger  ulcerations,  which,  by  the  persist- 
ence of  the  catarrh  or  through  other  unfavourable  circumstances, 
may  become  quite  deep,  and  even  rupture  into  neighbouring  organs. 
As  von  Esmarch  ^  states,  these  ulcers  are  sluggish  in  character,  heal 
badly,  and  lead  to  the  formation  of  cicatrices  and  polypi.  Accord- 
ing to  this  authority,  most  cases  occur  toward  the  end  of  exhaust- 
ing diseases  or  after  severe  injuries  and  operations,  and  produce 
death  by  colliquative  diarrhoeas. 

Follicular  ulcers  are  frequent  in  children  with  chronic  diar- 
rhoea. I  have  never  observed  this  form  of  ulceration  in  adults,  not 
even  in  those  suffering  from  severe  catarrh  of  the  large  intestine. 
On  the  other  hand,  I  have  repeatedly  seen  chronic  follicular  swell- 
ing, with  pain  and  other  disturbances,  in  catarrh  of  the  large  intes- 
tine and  rectum. 

3.  Tuhercular  ulcers  (see  Fig.  45).  These  result  from  swal- 
lowed tubercular  sputum,  from  tubercle  bacilli  which  have  reached 
the  rectum  by  means  of  the  blood  and  lymph  channels,  or  from 


DISEASES  OF   THE  RECTUM 


495 


mechanical  insults  to  the  anus  or  rectum.  In  tlie  case  from  which 
the  accompanying  illustration  is  taken,  the  probable  cause  of  the 
lesion  was  continued  contact  of  the  anal  mucous  membrane  with 
mechanically  and  chemically  irritating  evacuations.  The  patient 
suffered  from  intestinal  tuberculosis.  The  ulcers  are  formed  by  the 
breaking  down  of  tubercular  nodules  (lenticular  ulcer).  Similar  to 
tubercular  ulcers  of  the  rest  of  the  intestine,  those  of  the  rectum  are 


PlO.    45. TUBEKOULAK     AnAL     AND     EeCTAL     UlCEE,    WITH    IIeMOKKIIOIDAL     NuDULE. 

(Original  observation.) 

characterized  by  a  circular  arrangement.  ISTear  the  ulcers  fresh 
tubercular,  grayish,  globular  nodules  occasionally  develop,  undergo 
the  same  necrotic  process  (softening,  fatty  and  caseous  degenera- 
tion), and  produce  secondary  tubercular  ulcers.  We  have  already 
mentioned  that  tubercular  ulcerations  tend  to  spread,  and  to  cause 
periproctitis  and  rectal  fistulse. 

4.  Syphilitic  ulcers  of  the  rectum  occur  in  the  most   varied 


496  DISEASES  OF   THE  INTESTINES 

forms.  They  are  found  as  soft  chancres  (primary,  from  coitus 
per  anum ;  secondary,  from  infection  by  chancroidal  secretion)  or 
as  hard  chancres,  either  as  a  primary  infection  (very  rare),  or  more 
frequently  by  the  breaking  down  of  broad  condylomata  in  the 
neighbourhood  of  and  spreading  toward  the  anus.  They  may  occur 
as  gummatous  ulcers.  Gummata  may  be  found  in  various  stages  : 
true  gumma,  degenerated  gumma,  superficial  ulcer,  or  scar  tissue 
from  old  healed  ulcerations.  Frequently  we  can  also  distinguish 
the  more  recent  processes  (rounded  nodules  with  beginning  ulcera- 
tive degeneration,  and  containing  necrotic,  brownish-red  masses) 
from  the  older,  deep,  irregular  ulcerations. 

In  constitutional  syphilis  there  may  be  a  proliferation  of  the 
deep  layers  of  the  connective  tissue,  a  condition  von  Esmarch  ^  des- 
ignates as  gummatous  or  syphilitic  polypi.  Unlike  true  rectal 
polypi,  these  do  not  originate  in  the  mucous  membrane,  but  from 
a  proliferation  of  the  submucous,  submuscular,  or  subserous  cellular 
tissue.  Yirchow  has  therefore  called  them  granulation  tumours 
(granulomata).  When  these  heal,  cicatrices,  which  may  produce 
extensive  stenosis,  develop ;  these  will  be  described  later.  In 
marked  cases  the  entire  rectum  is  changed  into  a  rigid,  immovable 
funnel  with  immensely  thickened  walls.  If  the  lowermost  portion 
of  the  rectum  is  affected,  complete  destruction  of  the  sphincter 
may  result. 

5.  Gonorrhmal  ulcers.  Opinion  is  divided  as  to  whether  rectal 
ulcers  may  be  gonorrhceal  or  not.  While  Jullieu^  believes  in  their 
existence,  Baer^  considers  them  complications  (post-gonorrhoeal 
ulcerations),  particularly  since  no  gonococci  have  been  demonstrated 
in  the  excised  portions.  According  to  Baer,  these  ulcers  are  usually 
situated  upon  the  anterior  or  posterior  wall  of  the  anal  orifice  upon 
a  protrusion  of  its  mucous  membrane  or  of  a  hemorrhoidal  fold. 
The  surface  of  the  ulcer  is  always  directed  toward  the  lumen  of  the 
rectum. 

Symptomatology  and  Diagnosis 

The  first  symptom  observed  in  uncomplicated  ulcer  of  the  rec- 
tum is  a  change  in  the  evacuations.  The  stools  are  generally  thin 
and  fluid,  are  mixed  with  blood  and  pus,  have  a  very  fetid  odour, 
and  may  consist  only  of  blood  and  pus.  In  addition,  there  is  more 
or  less  marked  tenesmus  and  pain  radiating  to  the  bladder,  back, 
legs,  and  genitals.  The  subjective  symptoms  may  be  absent,  or 
may  not  be  prominent.     As  a  result  of  hemorrhage  and  suppura- 


DISEASES   OF   THE   RECTUM  497 

tion,  and  occasionally  from  fever,  the  patients  lose  considerable 
flesh  and  strength.  From  the  symptoms  above  enumerated  we  may 
assume  the  presence  of  ulcerative  processes  in  the  rectum.  For 
positive  diagnosis  a  local  examination  is,  however,  necessary. 

Careful  digital  exploration,  wherel)y  the  situation  and  nature 
of  the  ulcers  can  be  fairly  well  determined,  is  the  best  method  of 
examination.  It  is  also  desirable  to  inspect  the  mucous  memljrane 
by  means  of  a  speculum,  the  rectum  being  meanwhile  irrigated 
with  water.  In  this  manner  the  diagnosis  of  tubercular,  syphilitic, 
or  catarrhal  ulceration  can  usually  be  made  although  great  diflicul- 
ties  may  be  encountered, 

A  thorough  history  and  careful  study  of  the  other  clinical  symp- 
toms are  of  the  utmost  importance,  particularly  in  the  differentiation 
between  syphilitic,  dysenteric,  and  tubercular  ulcers.  We  must 
always  search  for  other  signs  of  syphilitic  or  tuberculous  disease. 
When  ulcers  appear  gonorrhoeal,  the  secretion  should  be  examined 
for  gonococci.  Similarly  the  tubercle  bacillus  must  be  looked  for. 
Small  portions  of  the  ulcers  may  have  to  be  excised  for  microscop- 
ical examination,  although  positive  results  are  not  always  obtained. 
Since  ulcerations  may  also  occur  from  ruptured  al)scesses  (salpin- 
gitis, Bartholinitis),  vaginal  examination  must  never  be  omitted. 

Treatment 

The  treatment  of  ulcers  of  the  rectum  is  very  tedious.  The 
reason  is  evident.  The  rectum  offers  the  best  chances  for  the 
propagation  of  ulcerative  processes,  but  the  worst  for  their  cure. 
The  long;  list  of  remedies  that  have  been  recommended  bears  out 
the  above  assertion. 

Ä  priot'i,  the  aim  of  our  therapy  would  seem  simple  enough — 
viz.,  wherever  possible,  to  eradicate  the  underlying  cause.  Where 
this  is  not  possible,  energetic  local  treatment  should  be  instituted. 

Prophylactic  treatment  is  often  employed  in  tuberculosis  and 
syphilis,  but,  unfortunately,  with  little  success.  The  chief  cause 
for  this  is  that  patients  regard  the  first  phases  of  their  rectal  affec- 
tion too  lightly,  and  therefore  present  themselves  for  treatment 
when  the  disease  is  already  far  advanced.  In  tubercular  rectal 
ulceration  the  patients  usually  have  ])ulmonary  or  intestinal  tuber- 
culosis, so  that  treatment  will  be  of  little  avail. 

The  conditions  are  more  favourable  in  ulcerating  chancres; 
these  may  be  healed  by  appropriate  anti-syphilitic  treatment  (Köb- 
ner).     Although  occasionally  cured  by  enei-getic  use  of  iodids  by 


498  DISEASES  OF  THE  INTESTINES 

mouth  and  rectum,  gummatous  ulcers  do  not  as  a  rule  respond  well 
to  treatment. 

The  treatment  of  gonorrhceal  ulcers  is  the  same  as  that  of  anal 
gonorrhoea — i.  e.,  astringent  and  antiseptic  solutions.  According 
to  Baer  and  others,  the  results  are  not  more  satisfactory  than  in 
chronic  urethritis. 

SymptomaÜG  treatment  should  be  directed  toward  the  increase 
of  general  health  and  strength  and  the  regulation  of  the  bowels. 
The  most  difficult  therapeutic  problem  is  the  cure  of  the  ulcers  by 
local  treatment.  The  number  of  preparations  recommended  for 
this  purpose  is  so  large  that  we  can  only  mention  the  most  impor- 
tant and  usual  ones.  These  include  nitrate  of  silver,  sulphate  of 
zinc,  tannin,  aceto-tartrate  of  aluminium  (Boas),  zinc-chlorid  solu- 
tions, and  carbolic  acid.  They  are  best  applied  in  the  form  of  rec- 
tal irrigations.  AUingham  recommends  the  use  of  soft  ointments 
applied  by  a  specially  constructed  ointment  spray. 

The  difficulty  in  local  treatment  lies  in  the  fact  that  in  advanced 
cases  constrictions  and  dilatations  almost  always  prevent  remedial 
agents  from  reaching  the  main  seat  of  the  disease.  Surgical  meth- 
ods have  therefore  been  attempted.  In  marked  stricture  of  the  anal 
orifice,  in  order  to  render  the  diseased  area  more  accessible,  poste- 
rior sphincterotomy  has  been  proposed.  In  ulcerations  higher 
up,  the  most  appropriate  treatment  would  seem  temporary  colos- 
tomy, mth  subsequent  local  treatment  through  the  intestinal  fistula. 
Except  in  cases  of  stenoses  (see  below),  but  little  experience  with 
this  operation  has  been  gathered.  When,  as  in  rectal  stenosis,  the 
disease  is  very  extensive  and  obstinate,  and  remains  uninfluenced 
by  all  palliative  measures,  the  only  remaining  procedure  is  resec- 
tion of  the  ulcerated  portion. 

6.  Strictures  of  the  Rectum 

The  causes  may  be  external  or  internal.  External  conditions 
are  disease  of  neighbouring  organs,  neoplasms,  plastic  exudates,  and 
vesical  calculi.  Internal  stricture  may  be  produced  by  simple 
obstruction  of  the  lumen  of  the  rectum,  by  fsecal  masses,  foreign 
bodies,  enteroliths,  prostatic  hypertrophy,  and  tumours,  or  by 
inflammatory  conditions  of  the  rectum  itself.  The  latter  are 
undoubtedly  the  most  frequent  causes  of  stricture,  and  therefore 
merit  thorough  discussion. 

All  lesions  of  the  rectum  which  heal  by  granulation  must  pro- 
duce narrowing  of  its  lumen.     Wherever  a  stricture  has  developed, 


DISEASES  OF   THE  RECTUM  499 

•its  increase  is  favoured  by  continued  irritation  of  the  adjacent 
tissues  or  by  an  extension  of  the  underlying  disease. 

We  have  previously  described  (page  494)  the  various  kinds  of 
ulcerations  of  the  rectum.  Syj)hilitic  and  dysenteric  ulcers  are  far 
more  apt  to  produce  extensive  stenosis  than  are  tubercular.  To 
what  extent  gonorrhoeal  processes  produce  stenosis  is  still  a  dis- 
puted question. 

No  doubt  there  is  an  inflammatory  rectal  stenosis  similar  to 
inflammatory  pyloric  hypertrophy  or  to  the  so-called  multiple 
submucous  sclerosis  of  the  French.  In  his  latest  work,  Bushe  * 
describes  a  very  characteristic  case.  Rieder^  also  believes  in  the 
existence  of  a  chronic  inflammatory  proctitis  with  destruction  of 
the  mucosa  and  proliferation  of  the  submucosa  and  muscularis. 

The  stricture  is  usually  situated  directly  above  the  anal  orifice, 
but  may  even  be  as  high  up  as  the  sigmoid  flexure.  (Several  years 
ago  I  saw  an  instance  of  this  latter  condition  in  a  young  woman. 
The  etiology  of  the  case  could  not  be  determined.)  The  strictured 
segment  may  be  either  straight,  corkscrew  shaped,  or  arborescent. 
The  wall  of  the  canal  may  consist  of  thick,  indurated  mucous  mem- 
brane without  ulcers,  or  there  may  be  numerous  primary  or  sec- 
ondary erosions.  In  the  most  complicated  cases  all  possible  patho- 
logical changes  may  be  combined— »viz.,  proctitis,  periproctitis,  fis- 
sures, hemorrhoids,  fistulse,  etc. 

The  greatest  number  of  rectal  stenoses  are  found  in  women  with 
present  or  previous  syphilitic  symptoms.  In  the  former  instance 
syphilitic  ulcers  or  gunmiata  may  be  found  on  the  genitals  and  in 
the  rectum,  or  in  the  rectum  alone.  These  conditions  are  not  dif- 
ficult to  diagnosticate,  although  the  manner  in  which  the  syphilitic 
virus  infects  new  areas  may  not  be  apparent.  According  to  Quenu 
and  Hartmann  \  the  lower  group  of  rectal  veins  anastomose  directly 
with  branches  of  the  external  pudendal,  which  latter  originate  in 
the  posterior  commissure  of  the  vulva,  the  chief  seat  of  syphilitic 
infection. 

The  question  of  post-syphilitic  strictures  has  caused  very  much 
discussion,  and  at  the  present  time  all  etiological  factors  have  not 
been  agreed  upon.  We  can,  however,  safely  say  that  syphilis  is 
undoubtedly  the  cause  of  a  large  number  of  rectal  strictures.  The 
fact  that  the  above  lesions  frequently  occur  with  other  syphilitic 
stigmata   (exostoses,  amylosis,  endarteritis,  syphiloma  of  the  liver, 


*  Log.  cit.,  page  109. 


500  DISEASES   OP   THE   INTESTINES 

etc.)  indicates  their  close  association  with  constitutional  syphilis. 
The  objection  of  the  opponents  of  this  theory  (JSIickeP,  Polchen  ^"j, 
that  rectal  stenoses  are  refractory  to  specific  treatment,  is  hardly 
convincing.  The  theory  that  rectal  ulcers  are  produced  by  trauma- 
tism does  not  ex23lain  their  greater  occurrence  in  women.  We  ad- 
mit that,  besides  syphilis,  gonorrhoea  and  catarrhal  inflammations  of 
the  rectal  mucous  membrane  may  produce  strictures.  Rieder  ^  has 
recently  demonstrated  that  there  is  a  proliferation  of  the  intima  of 
the  rectal  veins,  even  to  complete  obliteration,  while  the  arteries 
remain  intact.  This  condition  he  considers  characteristic  of  syph- 
ilitic rectal  stenosis. 

Symptomatology  ajstd  Diagnosis 

Obstruction  to  defecation  is  the  foremost  symptom  of  stricture 
of  the  rectum. 

As  in  carcinomatous  strictures  (already  discussed  on  page  318),  the 
early  symptoms  of  these  rectal  strictures  are  obscure  and  generally 
escape  observation.  The  patients  first  present  themselves  for  treat- 
ment when  symptoms  of  ulceration  or  of  increasing  rectal  stenosis 
become  prominent.  In  the  former  instance  there  is  a  bloody,  mu- 
cous, or  purulent  discharge ;  in  the  latter,  painful  tenesmus  with 
fragmentary,  scybalous,  small-calibred  or  semifluid  dejections.  The 
symptoms  of  ulceration  may  be  accompanied  by  those  of  stricture. 
Above  the  stricture  (in  the  sigmoid  flexure  or  higher)  abdominal 
palpation  reveals  fsecal  masses,  which  soon  produce  a  sacculated 
dilatation  of  this  part  of  the  large  intestine — an  important  symptom 
of  low  strictures.  There  may  be  so-called  "  false  diarrhoeas,"  which 
are  easily  mistaken  for  intestinal  catarrh. 

The  general  health  is  gradually  undermined  by  the  tenesmus 
and  loss  of  blood  and  pus.  It  is  surprising,  however,  to  note  how 
long  the  general  condition  of  patients  with  non-malignant  strictures 
remains  good.  This  applies  also  to  malignant  strictures,  though 
here  we  may  generally  detect  the  characteristic  cachexia.  Acute, 
complete  stenoses  or  perforations  into  the  neighbouring  organs  may 
take  place,  but  are  rare.  The  lower  the  stenosis  the  more  infre- 
quent these  perforations. 

Continued  ulceration  may  cause  extensive  destruction  of  the 
sphincter  ani.  The  symptoms  of  rectal  incontinence  then  appear, 
tenesmus  ceases,  and  there  is  a  profuse,  continuous  discharge  of 
blood,  pus,  and  mucus. 

The  diagnosis  of  rectal  stricture  is  readily  made.     Upon  intro- 


DISEASES  OF  THE  RECTUM  501 

auction,  the  finger  immediately  strikes  an  obstacle;  at  the  same 
time  we  are  informed  of  the  degree  of  the  stenosis,  at  least  of  its 
lower  (anal)  portion.  To  determine  the  size  of  the  stricture  and 
the  condition  beyond,  the  introduction  of  rectal  bougies  is  indis- 
pensable. As  already  mentioned  (page  81),  we  may  use  various 
instruments  for  this  purpose.  "We  should  always  remember  that 
we  are  introducing  the  instrument  into  a  cavity  whose  length, 
direction,  and  lateral  recesses  are  unknown,  and  that  by  this  pro- 
cedure we  cannot  determine  the  condition  of  the  rectal  wall  and 
the  presence,  extent,  and  depth  of  the  ulcerations.  Considering  all 
these  facts,  we  may  ask  whether  the  diagnostic  value  of  instrumen- 
tation is  as  great  as  its  dangers.  It  is  plain,  however,  that  thera- 
peutic bougieing  has  to  reckon  with  other  factors.  Bougieing  is 
only  absolutely  necessary  in  strictures  beyond  the  reach  of  the 
examining  finger,  for  here  the  diagnostic  difiiculties  cannot  other- 
wise be  overcome.  Thus  the  previously  mentioned  case  of  sigmoid 
stricture  (page  494)  had  passed  through  many  hands  before  the  cor- 
rect diagnosis  was  made.  We  have  already  pointed  out  the  charac- 
teristics of  stricture  of  the  sigmoid  flexure  and  of  the  upper  part 
of  the  rectum  (page  82).  I  agree  with  experienced  clinicians  that 
the  use  of  a  speculum  is  generally  unnecessary  for  the  diagnosis  of 
low-seated  strictures,  although  one  may  thus  obtain  a  better  idea  of 
their  character. 

The  examination  of  the  dejections,  their  form,  and  more  espe- 
cially the  admixture  of  purulent,  fetid,  bloody  masses,  completes 
the  clinical  picture  and  diagnosis.  As  already  stated,  changes  in 
the  stools  are  often  the  first  symptoms  to  alarm  the  patient,  and 
should  always  lead  to  careful  local  examination. 

DiFFEKENTIAL    DIAGNOSIS 

The  etiology  of  strictures  is  much  more  difiicult  to  determine 
than  is  their  diagnosis.  Since  they  will  scarcely  escape  a  careful 
examination,  we  need  not  here  consider  external  tumours,  exudates, 
etc.,  which  constrict  the  rectum.  Prostatic  tumours  and  enlarge- 
ments will  likewise  rarely  cause  error  in  diagnosis,  but  differen- 
tiation between  malignant  and  benign  rectal  strictures,  particularly 
between  carcinomatous,  luetic,  gonorrhoeal,  and  dysenteric  varieties, 
is  quite  difiicult. 

In  distinguishing  between  malignant  and  non-malignant  ste- 
noses, the  history  and  clinical  course  of  the  disease  are  frequently  of 
value.  The  existence  of  syphilitic  infection  or  of  a  previous  dysen- 
33 


502  DISEASES   OF  THE  INTESTINES 

tery  can  nsuallj  be  established.  Tbe  course  of  tlie  affection  is  more 
important.  The  patients  may  state  that  their  symptoms  date  back 
several  years — a  fact  of  great  significance  as  regards  the  kind  and 
character  of  the  stricture.  The  age  of  the  patient  and  the  absence 
of  cachexia  may  to  some  extent  speak  for  one  or  the  other  type  of 
stenosis. 

As  we  have  seen  in  the  section  on  Cancer  of  the  Rectum  (page 
321),  digital  examination  may  give  us  useful  information — e.  g.,  in 
the  differentiation  between  carcinomatous  and  syphilitic  strictures. 
ISTevertheless,  errors  may  occur.  In  such  cases  excision  and  micro- 
scopical examination  of  a  rather  large  piece  of  the  new  growth  may 
make  the  diagnosis  positive. 

The  differential  diagnosis  between  syphilitic  and  dysenteric  rec- 
tal strictures  is  very  difficult.  In  his  work  on  tumours,  Yirchow  ^^ 
states :  "  Gummatous  ulcers  resemble  diphtheritic,  and  more  espe- 
cially dysenteric,  ulcers.  This  similarity  is  so  marked  that  I  have 
often  been  in  doubt  as  to  whether  the  destructive  process  in  a  given 
case  was  syphilitic  or  dysenteric.  The  same  is  also  true  of  stric- 
tures. The  site  of  the  lesion  may  to  a  certain  extent  guide  us.  In 
dysenteric  processes  the  lesions  are  more  frequently  found  in  the 
sigmoid  flexure ;  in  syphilitic,  in  the  ampulla  of  the  rectum  or  close 
to  the  anus.  In  addition,  the  more  even  and  broader  ulcerations  of 
syphilis  contrast  with  the  eroded,  irregular,  superficial  and  deep 
ulcerations  of  dysentery."  In  view  of  the  rare  occurrence  of 
dysentery  in  our  country  [Germany]  the  clinical  differentiation  will 
usually  be  easy. 

Tubercular  rectal  stenoses  are  rare,  and  are  generally  accom- 
panied by  signs  of  tuberculosis  in  other  portions  of  the  body  (lungs, 
peritoneum,  other  intestinal  segments,  genito-urinary  system,  etc.) ; 
the  etiology  of  the  ulcers  may  be  determined  by  examination  of  the 
secretion  for  tubercle  bacilli.  When  suspecting  gonorrhoeal  stric- 
ture, gonococci  should  be  sought  for.  It  must  not  be  forgotten, 
however,  that,  especially  among  prostitutes,  the  simultaneous  occur- 
rence of  syphilis  and  gonorrhoea  is  by  no  means  rare. 

From  the  above  data  we  may  (perhaps  after  a  long-continued 
observation),  in  many  cases,  make  a  probable  or  even  a  positive 
diagnosis. 

Treatment 

Whatever  the  nat-ure  of  the  underlying  process,  internal  treat- 
ment of  strictures  of  the   rectum  is  useless.     Most  experienced 


DISEASES  OF  THE  RECTUM  503 

clinicians  agree  upon  the  futility  or  slight  value  of  antisjphilitic 
treatment.  According  to  dermatologists,  in  order  to  prevent  cica- 
tricial contraction,  radical  antisjphilitic  treatment  is  always  in- 
dicated in  fresh  gummatous  syphilis.  In  the  majority  of  cases  we 
must  alleviate  stenotic  symptoms  by  laxatives.  Drastic  drugs  are 
to  be  avoided.  Rhubarb,  frangula,  flowers  of  sulphur,  compound 
licorice  powder,  or  magnesia  usta,  in  conjunction  with  the  so-called 
"  constipation  diet "  (see  page  14:6),  are  usually  sufficient.  If,  as 
determined  by  external  palj^ation,  there  is  long-standing  cojorostasis, 
the  safest  procedure  is  the  administration  of  large  doses  of  castor 
oil  (2  to  3  tablespoonf uls,  repeated,  if  necessary,  for  several  days). 

The  best  palliative  measure  is  methodical  dilatation  of  the 
stricture  by  rectal  bougies.  Views  differ  widely  regarding  the 
value  of  this  method.  Most  surgeons  do  not  adopt  the  extreme 
view  of  Schuchardt,  Eieder,  and  others,  that  bougieing  should  be 
entirely  discarded.  In  several  cases  of  very  advanced  luetic  stric- 
ture I  have  achieved  remarkably  favourable  results  with  sounds, 
although  the  treatment  had  to  be  carried  out  three  times  a  week  for 
several  months.  I  consider  proctitis  or  periproctitis  positive  con- 
traindications to  the  use  of  bougies.  In  a  dissertation  upon  the  clin- 
ical material  of  G.  Lewin,  Alderhot  ^^  also  speaks  in  favour  of  bou- 
gieing. Before  beginning  treatment,  it  is  advisable  to  point  out  to 
the  patient  the  length  of  time  required,  as  well  as  the  possibility  of 
relapses  after  bougies  have  been  discontinued.  If  the  patient  is 
intelligent,  he  may  after  a  few  weeks  be  intrusted  with  the  instru- 
mentation himself,  and  the  result  occasionally  controlled  by  the 
physician.  We  begin  with  the  smallest  bougie  that  will  pass  the 
stenosis,  gradually  increasing  the  size.  The  instrument  should  be 
left  in  situ  several  minutes,  and,  to  aid  in  the  dilatation,  should  be 
given  gentle  rotary  movements. 

The  best  bougies  are  solid  soft-rubber  ones,  purchasable  every- 
where, or  Hahn's  hollow  bougies  containing  a  spiral  frame.  The 
latter  are  not  soft  enough  to  give  way  when  they  encounter  the 
obstruction,  but  are  sufficiently  elastic  not  to  cause  laceration.  If 
properly  curved  (Bushe),  the  following  instruments  are  also  rec- 
ommended :  French  bougies,  hard-rubber  or  glass  bougies  (von  Es- 
march),  and  olive  bougies  fashioned  after  Trousseau's  sounds.  Crede 
and  Körte  prefer  curved,  hard-rubber  bougies.  Because  of  their 
lack  of  danger  soft  instruments  are  to  be  preferred.  Where  dis- 
charges of  blood  or  pus  weaken  the  patient,  we  may  try  astrin- 
gent  irrigations   (aceto-tartrate   of   aluminium,   tannin,  nitrate   of 


504  DISEASES  OF  THE  INTESTINES 

silver) ;  for  obvious  reasons,  however,  sucli  irrigations  are  of  little 
benefit. 

If  the  above  palliative  measures  cannot  be  applied,  or  have 
proved  futile,  we  should  advise  operative  treatment.  There  are 
several  methods ;  opinion  regarding  their  respective  value  is  as 
yet  divided. 

These  methods  are  the  following :  («)  Lateral  incision  with  a 
scalpel  in  order  to  render  bougieing  easier.  This  has  not  met 
with  great  favour,  since  superficial  incisions  are  of  little  use  and 
deep  ones  dangerous,  (h)  In  annular  cicatricial  stenosis  of  the 
anus,  Dieffenbach  advocated  extirpation  of  the  stricture  and  draw- 
ing down  and  suture  of  the  distal  mucous  membrane  to  the  lower 
edge  of  the  wound,  (c)  In  very  marked  stenosis  of  the  anal  region 
and  of  the  lower  portion  of  the  rectum,  Pean  recommended  that 
the  canal  should  be  cut  longitudinally  and  the  cut  edges  sutured 
transversely,  similar  to  the  pyloroplasty  of  Heineke-Mikulicz. 
This  method,  however,  presupposes  a  stenosis  of  equal  degree 
throughout  and  the  absence  of  fistulae,  and  hence  will  be  of  use 
in  only  a  limited  number  of  cases,  (d)  Colostomy.  This  is  usually 
not  dangerous,  but  is  functionally  unsatisfactory.  The  method  first 
used  by  Thiem^^ — temporary  colostomy  and  subsequent  bougieing 
of  the  stenosis — gives  much  better  results.  As  soon  as  the  stenosis 
is  cured  (cure  naturally  proceeding  much  more  quickly  under  these 
circumstances)  the  artificial  anus  may  be  closed.  At  present  this  is 
the  best  and  undoubtedly  the  most  preferable  procedure,  because  it 
is  not  dangerous,  and  gives  the  best  functional  results.  It  is  doubt- 
ful, however,  whether  the  majority  of  stenoses  can  be  sufficiently 
dilated  to  permit  the  normal  passage  of  faeces  within  a  reasonable 
time.     Further  experience  in  this  field  is  necessary. 

Sonnenburg ^*,  and  recently  Kotter  ^^,  have  proposed  two  methods 
whose  value  can  only  be  determined  by  future  operations. 

(e)  In  very  extensive  syphilitic  (and  gonorrhoeal)  strictures, 
which,  owing  to  their  high  situation  and  extent,  cannot  be  extirpated, 
Sonnenburg  recommends  extirpation  of  enough  of  the  coccyx  and 
sacrum  to  lay  bare  the  callous  stricture  and  its  surroundings.  On 
account  of  the  extensive  adhesions  present,  the  peritoneum  is  not 
endangered.  The  whole  length  of  the  stricture  is  then  divided 
from  without  inward ;  the  sphincter  is  not  divided.  The  wound 
is  tamponed,  and  heals  slowly.  Later,  long-continued  bougie- 
ing is  necessary.  Sonnenburg  calls  this  operation  "  external  rec- 
totomy" 


DISEASES  OF  THE  RECTUM  505 

(/)  Following  the  principle  recommended  bj  the  American  sur- 
geon Bacon,  Rotter  connects  the  intestinal  segment  above  the  stric- 
ture (the  sigmoid  flexure  portion)  with  the  normal  segment  lying 
between  the  stricture  and  sphincter  ani.  In  two  out  of  three  cases 
this  operation  was  successful,  and  was  accompanied  by  good  func- 
tional results.  Rotter  calls  his  operation  '■'■  sigmoid  rectotomy T 
Aside  from  the  fact  that  this  procedure  circumvents  but  does  not 
remove  the  stricture,  it  has  a  limited  application,  for  it  can  only  be 
used  when  there  is  enough  healthy  rectum  above  the  sphincter  ani 
for  implantation  of  the  sigmoid  flexure  and  it  is  no  longer  possible 
to  treat  the  stricture. 

{g)  The  most  thorough  and  at  the  same  time  most  severe  opera- 
tion is  resection  of  the  rectuwj^  first  performed  by  James  Israel  in 
1885,  and  since  then  repeatedly  by  Schede  ^^  and  many  others. 
When  we  consider  the  difiiculties  of  this  operation,  the  results 
achieved  by  Schede  are  quite  satisfactory.  In  lY  cases  from 
Schede's  clinic,  recently  reported  by  Rieder^,  none  died  from  the 
operation.  Permanent  results  were  obtained  in  10  cases;  of  these, 
5  remained  cured  and  free  from  recurrence ;  the  remaining  5  had 
either  relapses  or  fistulse.  Of  the  5  cured  cases  (4  of  them  were 
positively  syphilitic)  1  was  well  since  one  year,  2  others  since  two 
years,  and  2  since  six  years.  It  is  very  diflicult  to  obtain  a  good 
functional  result  after  the  operation. 

It  is  only  from  rectal  examination  that  we  can,  in  a  given  case, 
determine  which  of  the  above  operations  is  the  most  appropriate. 
Besides,  the  surgeon  is  swayed  by  his  preference  for  one  or  the 
other  operation,  and  by  his  own  results. 

7.   Prolapse  of  the  Rectum  {Prolapsus  Recti) 

The  rectum  is  so  closely  connected  with  surrounding  tissues  that 
only  under  special  conditions  is  this  attachment  loosened.  Such 
conditions  are  for  the  most  part  found  in  children.  According  to 
the  statistics  of  Bokai  '^'^,  of  350  cases  of  prolapsus  recti,  the  greatest 
number  occurred  in  children  in  the  second  and  third  years  of  life, 
the  first  and  the  later  years  showing  a  markedly  diminished  predis- 
position to  the  affection.  Other  prominent  etiological  factors  are 
poor  general  health,  constipation,  respiratory  diseases  (especially 
pertussis),  and  catarrh  of  the  larger  intestine  (particularly  of  the 
rectum)  with  severe  tenesmus. 

In  adults,  besides  the  above  factors,  there  are  dysuria,  unnatural 
coitus,  senile  atrophy  of  the  muscles  of  the  pelvic  outlet  (levator 


506  DISEASES  OF   THE  INTESTINES 

ani,  rectal  sphincters,  and  retractors) ;  in  women,  overdistention  of 
the  muscles  of  tlie  pelvic  floor,  etc. 

The  prolapse  generally  develops  gradually;  at  first  the  anal 
mucous  membrane  protrudes  (as  it  does  physiologically  in  the  horse 
during  defecation) ;  later  there  is  a  protrusion  of  all  the  layers  of 
the  rectal  wall.  In  extensive  rectal  prolapse  the  peritoneal  fold  of 
Douglas  is  also  drawn  down.  The  sac  formed  in  this  manner  may, 
in  rare  instances,  contain  intestine,  ovaries  or  bladder — a  condition 
known  as  rectal  hernia.  True  rectal  is  to  be  sharply  distinguished 
from  hemorrhoidal  prolapse,  the  latter  being  easily  differentiated 
by  the  well-marked  bluish  nodules.  "We  shall  later  return  to  the 
subject  of  hemorrhoidal  prolapse. 

Symptomatology  and  Diagnosis 

The  first  symptoms  are  usually  not  well  marked,  and  hence 
have  rarely  been  observed.  The  patient's  attention  is  directed 
to  the  lesion  only  when  large  portions  of  the  rectum  prolapse  and 
are  not  spontaneously  reduced.  On  straining,  we  may  then  dis- 
tinctly see  the  rosettelike  protrusion  of  the  mucous  membrane  with 
the  central  opening  from  which  faeces  are  emptied.  When  the  pro- 
lapse is  reduced  the  examining  finger  can  easily  recognise  the  relax- 
ation of  the  sphincters.  At  first  the  prolapse  occurs  infrequently, 
and  only  from  severe  straining  at  stool ;  gradually  the  resistance  of 
the  sphincters  is  more  easily  overcome,  so  that  coughing,  laughing, 
sneezing,  and  even  walking,  cause  protrusion. 

In  consequence  of  mechanical  irritation,  particularly  in  the  be- 
ginning of  the  disease  when  the  rectum  is  unaccustomed  to  any  for- 
eign influences,  inflammation  with  subsequent  catarrh  of  the  mucous 
membrane  develop.  A  copious  discharge  of  viscid  mucoid  secre- 
tion follows.  Accompanying  this  condition  there  may  be  hemor- 
rhages, ulceration,  and,  where  long-continued  incarceration  exists, 
gangrenous  inflammation  with  necrosis  of  the  prolapsed  segment 
and  serious  sequelse.  In  this  manner  spontaneous  cure  often  re- 
sults. In  the  last  stages  of  thö  disease,  having  gained  a  certain 
amount  of  practice  in  the  rapid  reposition  of  the  prolapse,  the  pa- 
tient becomes  more  or  less  accustomed  to  the  condition. 

We  can  gauge  the  age  of  the  prolapse  by  its  characteristics. 
During  the  first  stages  it  is  succulent,  soft,  covered  with  mucus,  and 
rich  in  blood  supply  ;  later  it  becomes  tough,  smooth,  and  resembles 
epidermis.     This  latter  condition  favours  easy  reduction. 

The  occurrence  of  prolapse  with  simultaneous  descent  of  abdom- 


DISEASES  OF  THE  RECTUM  507 

inal  contents  is  of  clinical  importance.  In  sucli  cases  tlie  prolapse 
increases  in  size ;  the  orifice  of  the  rectum  is  then  pushed  toward 
the  coccyx,  and  does  not  regain  its  axial  position  till  the  hernial 
contents  are  reduced.  If,  as  the  result  of  marked  distention  or 
inflammation  of  the  rectum,  or  of  abnormal  tension  of  the  sphincter 
or  levator  ani,  the  intestinal  contents  become  incarcerated,  all  the 
sequences  of  intestinal  strangulation  may  ensue. 

The  diagnosis  of  prolapsus  recti  is  rarely  difiicult.  Careful  ex- 
amination will  nearly  always  prevent  error  in  differentiating  between 
rectal  and  hemorrhoidal  prolapse.  In  extreme  rectal  prolapse  it  is 
often  difiicult  to  determine  whether  or  not  intestinal  contents,  etc., 
are  present  in  the  peritoneal  sac.  There  are  numerous  reports  of 
unsuccessful  operations  due  to  this  error.  Careful  and  repeated 
examinations  (preferably  under  ansesthesia)  are  therefore  necessary. 

Intussusception  of  the  colon  must  be  considered,  as  it  frequently 
occurs  during  the  earlier  periods  of  life.  There  is  considerable 
difference  in  the  course  of  these  two  diseases  (see  page  387),  and 
difiiculty  in  their  differentiation  can  only  arise  when  we  have 
neither  reliable  history  or  observation  to  guide  us.  In  intestinal 
invagination  the  examining  finger  can  feel  the  rectum  outside  the 
intussusceptum  without  meeting  the  point  of  reduplication.  It  is 
important  also  to  note  that  in  prolapse  thei'e  is  a  sort  of  furrow 
between  the  base  of  the  prolapsed  portion  and  the  anal  ring,  which 
furrow  disappears  only  in  long-standing  cases.  In  a  prolapsed  and 
invaginated  colon  a  bougie  may  be  introduced  for  a  long  distance, 
while  in  rectal  prolapse  the  instrument's  progress  is  soon  stopj)ed. 

Treatment 

This  is  most  successful  during  the  early  stages.  At  such  times 
cure  may  be  obtained  by  regulation  of  the  bowels,  careful  avoidance 
of  straining,  and  by  local  tonic  treatment  (cold  irrigations  with  astrin* 
gent  solutions,  etc.).  Unfortunately  we  usually  see  cases  for  the 
first  time  when  they  are  far  advanced,  and  when  they  are  much  less 
amenable  to  conservative  treatment. 

The  age  of  the  individual  and  the  duration  of  the  prolapse  have 
an  important  bearing  upon  the  treatment.  In  very  old  prolapses, 
where  operation  is  declined,  internal  treatment  can  only  be  symp- 
tomatic. In  children  in  whom  the  prolapse  is  not  very  far  ad- 
vanced, active  internal  or  surgical  measures  are  always  indicated. 

Besides  careful  regulation  of  the  bowels  (one  semisolid  move- 
ment daily)  and  thorough  regional  treatment  with  astringents,  local 


508 


DISEASES  OF  THE  INTESTINES 


subcutaneous  injections  of  ergotin  (0.1  gm.  to  0.2  gm.  per  dose)  or 
strychnin  (0.001  to  0.002  gm.)  may  be  given.  This  treatment  has 
often  been  successful,  and  is  worthy  of  systematic  trial.     Should 

it  fail,  surgical  measures  must 
be  employed.  The  rectal  sup- 
port of  von  Esmarch  (see  Fig. 
46)  is  the  best  means  of  con- 
trolling the  prolapse  in  pa- 
tients who  complain  mainly  of 
the  discomfort. 

In  my  opinion,  the  indica- 
FiG.  46.-EECTAL  SuppoKT.   (von  Esmarch.)       tion  for   surgical    treatment, 

which  nowadays  has  entirely 
superseded  the  former  bloodless  methods  (actual  cautery,*  cauteri- 
zation with  mineral  acids,  etc.),  depends  upon  the  severity  of  the 
symptoms.  The  prolapse  j?er  se  is  certainly  no  indication  for  opera- 
tion, for  I  have  seen  patients  become  entirely  accustomed  to  their 
condition. 

The  question  of  operation  is  quite  different  where  there  is  diffi- 
culty in  replacing  the  prolapse,  where  there  is  any  inflammation  or 
hemorrhage,  and  where  the  bowel  protrudes  in  the  interval  of 
defecation.  We  should  lose  no  unnecessary  time  with  palliative 
treatment,  especially  since  the  present  state  of  surgery  has  robbed 
this  operation  of  its  dangers.  Unfortunately,  operation  does  not 
always  guard  against  relapses.  For  the  various  operative  procedures 
the  reader  is  referred  to  surgical  text-books. 

8.    Hemorrhoids 

These  are  diffuse  or  circumscribed  dilatations  of  hemorrhoidal 
veins  situated  in  the  subcutaneous  tissue  of  the  outer  anal  region  and 
in  the  submucous  tissue  of  the  lower  rectal  segment.  The  old 
classification  of  hemorrhoids  into  external,  internal,  arid  mixed 
groups  still  holds  good.  In  mixed  hemorrhoids  the  extra-rectal 
portion  is  usually  small  and  the  intra-rectal  portion  well  developed. 
We  find  the  statement,  particularly  in  older  literature,  that  hemor- 
rhoids may  extend  over  the  entire  rectum  and  even  into  the  sigmoid 
flexure.     If  this  condition  occurs  at  all,  it  certainly  is  extremely 

*  [This  certainly  is  a  surgical  procedure — in  fact,  the  cautery  operation  at  the 
present  time  is  the  favourite  method  in  the  United  States  for  uncomplicated  rectal 
prolapse. — Tr.] 


DISEASES  OP  THE   RECTUM  509 

rare.  For  the  most  part  hemorrhoids  are  undoubtedly  caused  by 
hindrance  to  the  return  of  blood  to  the  vena  cava  and  portal  vein. 
We  distinguish, 

1.  Internal  causes,  within  the  rectal  mucous  membrane. 

2.  External  causes,  which  act  by  compressing  the  hemorrhoidal 
plexus. 

3.  Disturbances  of  the  general  circulation. 

Internal  factors  produce  three  quarters  of  all  hemorrhoidal  for- 
mations. Faecal  stasis  is  the  most  important  and  frequent  of  these 
causes.  A  vicious  circle  develops ;  coprostasis,  pressure  on  the 
hemorrhoidal  veins  (further  increased  by  straining  of  the  abdominal 
muscles),  and  formation  of  hemorrhoidal  nodules,  followed  by 
mechanical  intestinal  stenosis,  stasis,  proctitis,  increased  constipa- 
tion, etc. 

Other  changes  in  the  mucous  membrane  of  the  rectum  and  other 
parts  of  the  large  bowel  (stenosis,  new  growths,  foreign  bodies, 
prostatic  enlargement),  by  preventing  the  normal  passage  of  faeces, 
may  give  rise  to  hemorrhoids.  As  in  cancer  of  the  rectum,  we 
may  observe  the  paradox  of  a  diarrhoea  due  to  coprostasis  above 
a  stenosed  segment.  Hemorrhoids  are  also  found  in  chronic 
diarrhoea,  particularly  in  catarrh  of  the  large  intestine.  In  such 
cases  the  hemorrhoids  may  be  caused  by  the  tenesmus,  hyperaemia, 
and  perhaps  also  by  the  inflammation  of  the  rectum  and  lower  seg- 
ments of  the  large  intestine. 

The  external  causes  of  hemorrhoids  are  tumours  of  the  neigh- 
bouring organs  which  retard  the  rectal  circulation.  The  simplest 
example  of  this  is  pregnancy,  during  which,  according  to  Budin^^, 
35  per  cent  of  all  hemorrhoidal  cases  develop.  These  disappear 
after  the  puerperium.  Tumours  of  the  uterine  adnexa,  retroflexion 
and  tumours  of  the  uterus,  disease  of  the  urethra  and  bladder,  par- 
ticularly such  as  affect  the  contractility  of  the  latter  organs,  may 
also  produce  hemorrhoids. 

Formerly  disturbances  of  circulation  (third  cause)  were  regarded 
as  the  chief  source  of  hemorrhoids.  Even  at  present  similar 
statements  are  found  in  almost  all  text-books  of  special  pathology. 
ISTothnageP^  mentions  the  rarity  of  hemorrhoids  in  stasis  of  the 
portal  system,  and  in  diseases  of  the  heart  and  lungs.  He  states 
that  in  cardiac  insufiiciency  the  pathological  increase  of  pressure  is 
spread  over  so  large  a  vascular  area  that  it  would  scarcely  affect  the 
hemorrhoidal  plexus  in  the  manner  formerly  assumed.  My  own 
experience  also  speaks  against  the  theory  of  hemorrhoids  from  gen- 


510  DISEASES  OP  THE   INTESTINES 

eral  vascular  congestion.  Even  if  the  two  conditions  coexisted  it 
would  still  have  to  be  demonstrated  that  the  hemorrhoidal  compli- 
cation was  not  due  to  the  constipation  present. 

Bouchard  found  hemorrhoids  in  28  per  cent  of  cases  of  chole- 
lithiasis. 'No  comment  on  this  is  found  in  the  classical  monograph 
of  Naunyn,  and,  as  far  as  I  know,  this  observation  has  not  been 
confirmed.  It  does  not  agree  with  my  own  experience.  That 
hemorrhoids  may  occasionally  occur  in  choleHthiasis  is  not  remark- 
able, for  it  is  well  known  that  a  large  proportion  of  these  patients 
suffer  from  constipation. 

Reredity  is  often  mentioned  as  a  predisposing  factor  in  hemor- 
rhoids, but  in  all  probability  there  is  really  hereditary  intestinal 
atony,  a  condition  not  at  all  infrequent. 

It  has  often  been  demonstrated  that  a  sedentary  hfe  predisposes 
to  hemorrhoids,  but  here  again  the  hemorrhoids  result  from 
habitual  constipation. 

Age  and  Sex. — That  hemorrhoids  is  really  a  disease  of  advanced 
life  follows  both  from  the  underlying  conditions  producing  tlie  dis- 
ease, and  from  the  lessened  elasticity  of  the  vessels  at  this  time  of 
life.  (I  might  mention  that  Lannelongue  ^"^  reports  a  case  of  hemor- 
rhoids in  a  newly  born  infant.)  It  is  quite  striking  (and  my  obser- 
vations upon  numerous  cases  confirms  this)  that  in  the  majority  of 
instances  hemorrhoids  are  more  frequently  found  in  men,  whereas 
habitual  constipation  occurs  oftenest  in  women.  Besides  this,  the 
occupation  of  women  is  more  restful  and  quiet  than  that  of  men. 
I  can  only  explain  this  fact  by  the  numerous  venous  plexuses  in 
the  female  genitals,  which,  while  not  entirely  preventing,  certainly 
make  the  occurrence  of  varicose  conditions  very  difficult. 

In  my  opinion,  the  oft-mentioned  distinction  between  stout  and 
thin  auEemic  hemorrhoidal  patients  will  as  little  withstand  scientific 
criticism  as  the  distinction  between  stout  and  lean  persons  with  dia- 
betes or  constipation.  This  theory  is  a  remnant  of  the  old  teaching, 
that  hemorrhoids  exert  a  beneficial  infiuence  upon  the  general  sys- 
tem. It  is  true,  as  Nothnagel  says,  that  we  find  hemorrhoids  much 
more  rarely  in  stout  individuals,  but  this  is  solely  because  the  tense, 
firm  connective  tissue  here  present  greatly  retards  the  development 
of  venous  dilatation.  Conversely,  in  cachectic  individuals  who  do  not 
suffer  from  severe  constipation  we  may  often  observe  hemorrhoids. 

Anatomically  we  differentiate  between  diffuse  dilatation  of  the 
rectal  veins  and  true  hemorrhoidal  nodules.  The  first  generally  form 
a  visible  rosette,  consisting  of  dilated,  often  spirally  twisted  veins, 


DISEASES  OP  THE  RECTUM  511 

under  the  skin  or  mucous  membrane.  Hemorrhoidal  nodules,  on 
the  other  hand,  vary  greatly  in  size,  and  are  single  or  multiple. 
When  multiple,  they  surround  the  anus  circularly  or  wreathlike, 
and  are  either  sessile  or  pedunculated.  Inflammatory  adhesions 
may  produce  a  confluence  of  the  hemorrhoids,  and,  as  a  result,  large, 
almost  angiomatous  masses  are  formed.  The  hemorrhoids  may, 
however,  atrophy,  and  become  covered  with  epidermis.  Their  ori- 
ginal character  can  then  only  be  recognised  by  their  bluish  colour, 
their  consistency,  and  their  characteristic  arrangement.  By  throm- 
bosis and  calcification  of  the  veins  so-called  phleboliths  may  be 
formed. 

At  present  our  views  regarding  the  histological  character  of 
these  varices  differ.  We  shall  not  enter  into  a  minute  discussion 
of  this  subject,  but  only  mention  that  Reinbach  ^\  who  has  recently 
carefully  studied  the  histological  structure  of  hemorrhoids,  concludes 
that  they  are  not  varicose  veins,  but  true  benign  tumours — i.  e., 
angiomata. 

Hemorrhoidal  may  conduce  to  rectal  catarrh,  with  more  or  less 
marked  mucous  secretion  (so-called  "  mucous  hemorrhoids  ").  Fis- 
sures and  excoriations  occur  quite  frequently,  and  may  lead  to 
abscesses,  fistulse,  and  (rarely)  to  very  severe  inflammation  and  peri- 
tonitis. 

■    Symptomatology 

The  former  view  that  hemorrhoids  was  a  constitutional  disease 
(even  nowadays  we  speak  of  a  "  status  hemorrhoidalis  "),  explains 
whv  the  description  of  this  disease  was  unnecessarily  extensive. 
Many  indefinite  abdominal  disturbances  and  circulatory  and  re- 
spiratory symptoms  were  attributed  to  hemorrhoids.  Venesection, 
which  prevailed  even  to  the  middle  of  this  century,  was  one  of  the 
consequences  of  these  theories. 

At  present  hemorrhoids  are  viewed  from  a  purely  local  stand- 
point ;  we  treat  the  hemorrhoidal  nodule,  and  not  the  hemorrhoidal 
diathesis.  We  must  not  entirely  relinquish  the  old  theory  of  a  gen- 
eral disturbance  brought  about  by  the  "  status  hemorrhoidalis."  We 
must  admit  that  certain  definite  symptoms  closely  associated  with 
altered  blood  pressure  are  produced  by  the  hemorrhoidal  varix; 
but  many  mild  and  (particularly  in  cachectic  persons)  severe  cases 
run  their  course  without  symptoms.  When  present,  the  symptoms 
are  generally  limited  to  the  diseased  area,  although,  as  already  inti- 
mated, they  may  extend  to  other  regions  of  the  body. 


512  DISEASES  OF   THE  INTESTINES 

The  local  symptoms  are  constipation,  a  feeling  of  pressure  and 
heaviness  in  the  rectum,  tenesmus,  and  itching  and  burning  in  the 
anal  region.  Defecation  usually  brings  relief.  In  external  hemor- 
rhoids there  is  also  more  or  less  discomfort  in  sitting,  even  upon  a 
soft  pillow,  and  in  riding,  bicycling,  jumping,  and  gymnastics. 

These  symptoms  may  be  accompanied  by  hemorrhages,  slight  in 
amount  or  (rarely)  sufficiently  severe  to  cause  the  most  profound 
anaemia  or  even  death.  The  bleeding  may  recur  periodically. 
Hemorrhages  are  often  preceded  by  increased  hemorrhoidal  symp- 
toms— feeling  of  congestion,  tenesmus,  severe  pains  radiating  to  the 
bladder,  etc.  With  the  onset  of  the  bleeding  these  symptoms  dis- 
appear. 

Strangulation  of  protruding  hemorrhoidal  nodules  constitutes 
one  of  the  most  painful  complications.  The  masses  which  have 
been  protruded  from  the  anal  fold  by  straining  usually  return 
easily,  either  spontaneously  or  by  manipulation.  They  may,  how- 
ever, remain  prolapsed,  and  become  swollen  and  inflamed ;  an  in- 
flammatory cedema  then  develops  about  the  anus ;  the  patients 
suffer  unbearable  pain,  and,  as  in  strangulated  hernia,  may  collapse. 
If  strangulation  is  not  relieved,  the  nodules  may  become  gangre- 
nous and  necrotic,  or  a  purulent  inflammation  with  its  serious 
sequences  may  result. 

In  very  old  cases,  in  consequence  of  paresis  of  the  sphincter, 
the  nodules  may  prolapse  in  walking,  bending,  coughing,  laughing, 
sneezing,  etc. 

As  already  mentioned,  inflammation  of  intra-rectal  hemorrhoids 
may  produce  symptoms  of  acute  proctitis — severe  pain,  repeated 
and  increasing  tenesmus,  sphincteric  spasm,  etc.,  and  occasionally 
fever. 

General  disturhances  are  more  apt  to  occur  in  chronic  hemor- 
rhoidal disease.  Besides  chronic  anaemia  many  patients  suffer  from 
abdominal  fulness  and  pressure,  necessitating  the  loosening  of 
clothing.  The  passing  of  flatus  affords  temporary  relief.  There 
may  also  be  severe  pain  in  the  back,  increased  by  bending  or  other 
active  motion.  Some  patients  complain  of  sciatica,  and  resort  unsuc- 
cessfully to  bath  treatment.  Certain  nervous  symptoms  are  also 
present — a  feeling  of  fulness  in  the  head,  dizziness,  nausea,  floating 
bodies  before  the  eyes,  etc. 

These  symptoms  may  be  considered  neurasthenic,  or,  to  be  more 
modern,  evidences  of  auto-intoxication,  or  perhaps  as  the  result  of 
habitual  constipation.     "We  must  admit  that  there  remain  symptoms 


DISEASES  OP  THE  RECTUM  513 

which  can  only  be  explained  by  changes  in  blood  pressure  in  the 
vena  cava  and  portal  vein.  If  we  remember  that  an  accumulation 
of  gas  in  the  stomach  or  intestine  not  only  gives  rise  to  local  dis- 
comfort, but  also  to  general  disturbances — pressure  in  the  head, 
feelings  of  fear,  palpitation,  etc. — and  if  we  recall  the  disturbances 
that  occur  in  the  beginning  of  menstruation,  we  must  acknowledge 
the  correctness  of  this  view.  The  disappearance  of  these  symp- 
toms, with  the  relief  of  the  constipation  is  no  proof  that  they 
depend  upon  that  condition,  for  the  hemorrhoidal  affection  is  at  the 
same  time  favourably  influenced. 

Diagnosis  and  Differential  Diagnosis 

In  the  great  majority  of  cases  the  diagnosis  is  easy.  Under  no 
circumstances  must  it  be  based  entirely  upon  the  statements  of  the 
patient.  Inspection  of  the  anal  region  alone  is  not  sufficient ;  the 
rectum  must  always  be  included,  and,  in  women,  the  genital  organs. 
Treatment  and  prognosis  are  considerably  influenced  by  the 
results  of  such  examination.  If  internal  hemorrhoids  are  sus- 
pected, they  are  best  brought  to  view  by  having  the  patient  strain 
strongly.  It  is  best  to  first  give  an  enema  of  warm  salt  water, 
and  then  to  have  the  patient  strain  while  sitting  upon  a  chamber 
filled  with  warm  water.  If  this  does  not  succeed,  a  rectal  specu- 
lum must  be  used.  We  should  avoid  the  tubular  speculum,  which 
pushes  the  hemorrhoidal  nodes  aside,  but,  under  the  precaution  men- 
tioned in  the  General  Division,  use  the  grooved  instrument  (page 
80).  Erosions,  ulcerations,  proctitis,  fissures,  fistulas,  etc.,  must  also 
be  looked  for. 

The  diferential  diagnosis  is  rarely  difficult.  Broad  condylom- 
ata can  only  be  mistaken  for  hemorrhoids  when  neither  has  before 
been  seen.  It  may  be  more  difficult  to  distinguish  hemorrhoids 
from  beginning  carcinoma  and  ulcerations.  Since  hemorrhoids 
ulcerate  very  readily  and  leave  deep  lesions,  error  can  only  be 
avoided  by  careful  consideration  of  all  accompanying  circumstances. 
The  distinction  between  rectal  polypi  and  hemorrhoids  is  readily 
made,  although  polypi  may  closely  resemble  thrombosed  varices. 
In  most  instances  careful  and  repeated  examination  will  scarcely 
leave  room  for  doubt.  This  is  also  true  of  the  differentiation  between 
prolapse  of  hemorrhoids  and  of  the  rectum. 


514  DISEASES  OP   THE  INTESTINES 


Treatment 

Wherever  possible,  treatment  should  be  directed  toward  the 
underlying  cause. 

Since  constipation  is  the  most  frequent  etiological  factor,  we 
begin  with  its  discussion.  In  referring  to  the  regulations  previ- 
ously described  for  the  treatment  of  this  condition,  we  have  only  to 
point  out  special  peculiarities  which  exist  in  the  constipation  of 
these  patients.  Proper  diet  is  of  the  greatest  importance.  We 
must  distinguish,  however,  between  hemorrhoids  with  and  without 
bleeding,  and  between  insignificant  and  profuse  hemorrhages. 

The  diet  must  be  carefully  regulated  in  patients  with  severe 
and  habitual  or  with  profuse  and  periodical  hemorrhages.  Spiced, 
sharp,  piquant  foods  and  drinks,  as  well  as  alcoholic  beverages, 
particularly  those  of  stronger  concentration,  must  be  avoided. 
Further  dietetic  restrictions  are  unnecessary.  It  is  obvious  that 
over-action,  excessive  walking,  horseback  riding,  gymnastics,  bicy- 
cling, etc.,  are  to  be  forbidden.  If  there  are  no  hemorrhages,  or  if 
they  are  insignificant,  the  diet  should  be  that  of  chronic  constipa- 
tion, with  due  consideration  to  the  general  health  and  nutritive 
condition  of  the  patient.  A  so-called  "  bland  diet,"  still  advised  in 
many  text-books,  is  absolutely  wrong.  The  favourable  influences 
of  diet  may  be  further  increased  by  active  and  passive  motion, 
rowing,  room  gymnastics,  billiard  playing,  bowliug,  tennis,  Swedish 
movements,  and  massage.  Owing  to  the  continual  local  friction 
and  increased  circulatory  disturbances,  horseback  riding,  and  prob- 
ably also  bicycling,  act  unfavourably. 

If  diet  alone  does  not  produce  sufficient  evacuations,  it  must  be 
aided  by  appropriate  laxatives.  For  this  purpose,  the  sulphur 
preparations  (flowers  of  sulphur,  one  teaspoonful  t.  i.  d),  and  laxa- 
tives containing  them  (compound  licorice  powder,  one  teaspoonful 
morning  and  evening),  have  been  long  and  deservedly  valued. 
They  operate  in  accordance  with  the  tenets  of  the  old  school : 
"  Cito.,  tuto  et  juGundeP  Whenever  a  change  of  remedies  is  indi- 
cated, the  other  laxatives  mentioned  in  the  chapter  on  Habitual 
Constipation  may  be  used,  though  the  above  preparations  will  gen- 
erally sufiice  for  a  long  time.  The  drastic  cathartics  are  said  to  be 
harmful  in  the  treatment  of  this  constipation.  Recently  they  have 
been  added  to  the  causative  factors  of  hemorrhoids  (Rosenheim  ^^), 
It  is  certainly  an  exaggeration  to  regard  drastics  as  productive  of 


DISEASES  OF  THE  RECTUM  515 

hemorrlioids,  but  in  some  instances  it  does  no  harm  if  the  physician 
supports  such  theories. 

Enemata  are  rarely  indicated  in  hemorrhoids,  for  manipulations 
with  the  usual  rectal  tubes  are  apt  to  irritate,  lacerate,  and  inflame 
the  hemorrhoidal  nodules.  Chemical  agents,  including  oil,  added 
to  enemata,  also  act  harmfully.  This  applies  particularly  to  glyc- 
erin, which  causes  severe  pain  and  tenesmus. 

Almost  all  text-books  advise  avoidance  of  sexual  excesses,  and 
claim  they  may  produce  hemorrhoids.  This  statement  is  true,  in  so 
far  as  these  should  be  avoided  by  healthy  as  well  as  diseased  indi- 
viduals. That  sexual  excesses  are  especially  harmful  to  those  with 
hemorrhoids  seems  to  me  to  be  based  on  mere  speculation,  and  not 
upon  scientific  experience.  I  cannot  comprehend  how  a  temporary 
congestion  of  the  genitals  can  produce  the  serious  results  described. 

The  use  of  baths  and  mineral  waters  must  be  briefly  touched 
upon.  Only  those  watering  places  which  contain  both  appropriate 
baths  and  appropriate  laxatives  (sodium  chloride  or  sulphate)  come 
into  consideration.  First  and  foremost  are  the  cold  saline  springs 
of  Kissingen  and  Homburg,  then  the  sodium  sulphate  waters  of 
Marienbad,  Tarasp,  Elster  ("  Salt  Spring "),  Franzenbad  ("  Salt 
Spring  "),  Rohitsch,  and  others.*  In  some  watering  resorts  (Elster, 
Marienbad,  Franzenbad)  persons  ansemic  from  loss  of  blood  may 
also  use  an  iron  spring.  In  recent  times — even  medicine  follows 
fashion,  as  proved  by  the  yearly  increasing  number  of  people  who 
visit  these  springs — great  health-giving  properties  have  been  attrib- 
uted to  mineral  waters.  Convinced  by  numerous  excellent  results 
from  a  sojourn  at  these  springs,  many  patients  visit  them  on  their 
own  account  and  recommend  their  use  to  others.  As  physicians, 
we  must  as  far  as  possible  consider  the  wishes  of  our  patients,  but 
we  should  also  know  the  limits  of  the  action  of  these  cures,  and  not 
promise  greater  results  than  actually  occur.  We  must  admit  that 
these  springs  generally  affect  the  hemorrhoidal  disease  very  favour- 
ably. This  is  quite  natural,  for  the  patients  find  themselves  in 
almost  ideal  surroundings  for  the  treatment  of  their  disease.  The 
use  of  aperient  waters,  the  necessary  exercise,  the  appropriate  diet, 
and,  not  the  least,  the  hygiene  of  the  anal  region  secured  by  numer- 
ous baths,  all  combine  to  produce  a  condition  never,  even  under  the 
best  of  circumstances,  obtainable  at  home.     But  with  this,  however, 


*  [For  corresponding  springs  and  wells  in  the  United  States,  see  pp.  161  and 
162.— Tr.] 


516  DISEASES  OP  THE  INTESTINES 

balneotlierap}^  finds  its  limitations.  As  soon  as  the  patients  resume 
their  usual  habits  of  life  the  old  condition  returns,  and  the  dearly 
bought  sojourn  at  the  springs  loses  its  magic.  It  is  therefore  the 
duty  of  the  physician  to  explain  to  the  patient  what  benefit  he  may 
expect  from  his  course  of  waters,  so  that  gain  in  health  and  neces- 
sary sacrifice  of  time  and  money  may  be  properly  proportioned. 
Permanent  good  often  results  from  repeated  yearly  visits  to  the 
baths  and  sj^rings,  but  this  cannot  be  determined  beforehand. 

Of  the  symptomatic  remedies  for  external  and  mixed  hemor- 
rhoids, the  first  is  the  toilet  of  the  anus.  The  patient  is  to  keep  the 
anal  region  absolutely  clean.  After  every  act  of  defecation,  this 
region  and  the  hemorrhoids  themselves  are  to  be  carefully  washed 
with  absorbent  cotton  (not  sponges)  dipped  in  a  cold  three-per-cent 
boric-acid  solution,  or,  what  I  especially  recommend,  a  tannin  solu- 
tion (teaspoonful  to  a  quart  of  water).  Cold  antiseptic  or  astrin- 
gent washings  are  very  agreeable  to  the  patient,  and  are  to  be  re- 
peatedly used.  We  should,  however,  always  study  our  patients 
before  giving  directions.  I  know  from  experience  that  in  neuras- 
thenics such  regulations  may  lead  to  quite  unpleasant  consequences. 
The  patients  examine  their  anus  all  day  long  by  means  of  mirrors 
and  reflectors,  just  as  tongue  h^^pochondriacs  do  their  tongues. 

The  most  important  complications  of  hemorrhoids  are  severe 
periodic  or  marked  chronic  hemorrhages.  In  milder  bleeding  treat- 
ment is  scarcely  necessary.  In  severe  hemorrhage  it  is  best  not  to 
delay  too  long  with  ineffectual  remedies  such  as  the  introduction  of 
ice,  injections  of  tannin  or  liquor  ferri  into  the  rectum.  By  means 
of  a  speculum  we  tampon  the  rectum  with  gauze  or  cotton  dipped 
in  liquor  ferri  or  ferripyrin  solution.  As  in  uterine  hemorrhages, 
hot  irrigations  (35°  to  40°  C.)  have  been  recommended  by  several 
authors  (Sandowski  and  others).  If  these  measures  do  not  control 
the  bleeding,  the  bleeding  vessels  or  tissue  must  be  sought  for  and 
tied  off.* 

In  continuous  hemorrhages,  particularly  where  there  is  ansemia 
and  general  weakness,  I  would  recommend  witch  hazel.     I  use  the 

*  [Firm  packing  of  the  bleeding  area  with  dry  gauze  (if  necessary  under  general 
anfesthesia)  is  the  simplest  and  surest  of  the  non-operative  means  of  arresting 
hemorrhage.  The  hard  clot  and  the  dirty,  slowly  healing  slough  after  the  applica- 
tion of  the  liquor  ferri,  make  its  employment  undesirable.  I  have  seen  rapid  and 
permanent  arrest  of  rectal  hemorrhage  follow  the  direct  application  of  cotton 
swabs  soaked  with  fifty-per-cent  antipyrin  solution  to  the  bleeding  surface.  Per- 
haps, too,  the  local  use  of  solutions  of  suprarenal  extract  would  be  effectual.  Ab- 
solute rest  is  of  course  essential  to  arrest  of  hemorrhage. — Tr.1 


DISEASES  OF  THE  RECTUM  5I7 

fluid  extract  exclusively  in  teaspoonful  doses  three  times  daily.  I 
have  had  no  experience  with  the  dry  extract  "  hamamelin  "  (dose, 
■0.05  to  0.06  gram)  recommended  by  Soulier^  for  the  same  purpose. 
Since  the  different  preparations  in  the  market  vary  in  strength,  we 
should  use  a  reliable  one.  After  an  extended  experience  I  do  not 
s,t  all  doubt  the  action  of  hamamelis  in  hemorrhoidal  hemorrhage. 
The  remedy  may  be  taken  for  weeks  and  months  without  producing 
untoward  symptoms.  In  continuous  hemorrhages  I  have  the  pa- 
tients take  the  drug  regularly  six  to  eight  weeks. 

Ergotin,  hydrastis  canadensis,  liq.  pot.  arsenites,  glycerin,  and 
other  remedies  have  been  recommended  in  hemorrhages  of  this 
character,  but  no  definite  proof  of  their  favourable  action  exists. 
Personally,  I  have  had  no  experience  with  them. 

Reposition  is  the  chief  measure  in  strangulation  of  varix  nodules. 
This  is  best  carried  out  with  the  patient  lying  on  his  side,  and  the 
hemorrhoidal  mass  and  the  parts  about  freely  smeared  with  an  oint- 
ment containing  cocain,  eucain,  or  opium,  or  with  olive  oil.  Gentle 
pressure  must  be  made.  IS^arcosis,  when  possible,  is  preferable. 
Schleich's  local  anaesthesia,  however,  is  even  better.  Leeches  aj)- 
plied  to  the  anus  (but  not  to  the  varices)  are  very  useful  in  reposi- 
tion. After  an  abundant  hemorrhage  the  hemorrhoids  are  easily 
replaced.  When  gangrene  has  occurred  the  nodules  should  be 
dusted  with  an  antiseptic  powder  (iodoform,  airol,  xeroform,  etc.).* 

Besides  these  important  complications,  there  are  inflammatory 
swellings  and  excoriations  of  external  and  internal  hemorrhoids. 
In  the  former,  anaesthetic  suppositories  (cocain,  eucain,  opmm, 
belladonna,  and  morphin)  are  generally  useful.  Unna,  Kosso- 
budskji^,  and  MacdonakP^  recommend  the  following  suppositories  : 

5i  Chrysarobin 0.08 

Iodoform ^-^^ 

Ext.  bellad 0.01 

Butyr.  cacao ^-00 

D.  t.  dos.  1^0.  X. 

S.  :  Apply  one  suppository  two  to  three  times  daily. 


*  [If  the  patient  refuse  ana?sthesia  or  operation,  and  reposition  otherwise  is  im- 
possible, rest,  local  application  of  ice,  and  free  inunctions  with  gallic  ointment, 
with  opium,  cocain,  belladonna,  etc.,  are  in  order.  Under  these,  reduction  in  size 
often  follows  and  reposition  is  then  possible.  It  would  be  interesting  to  try  the 
suprarenal  extract  in  these  conditions.  Occasionally  gangrene  and  a  spontaneous 
•cure  occur. — Tr.] 
34 


518  DISEASES  OP  THE  INTESTINES 

It  would  be  interesting  to  know  which  of  these  three  remedies^ 
ehrysarobin,  iodoform,  or  belladonna,  is  the  effectual  one. 

As  may  be  seen  from  their  composition,  styptic  properties  are 
attributed  to  these  suppositories.  For  a  like  purpose,  Rosenheim  * 
recommends  the  injection  of  a  very  weak  solution  of  nitrate  of  sil- 
ver (one  gram  of  a  one-half-per-cent  to  one-per-cent  solution)  into 
the  rectum  by  means  of  a  specially  devised  syringe.  Anaesthetic 
ointments  may  also  be  applied  with  the  collapsable  tube,  previously 
described. 

In  external  hemorrhoids  the  various  ointments  again  come  into 
consideration.  Chrysarobin  enjoys  a  special  reputation.  The  oint- 
ment recommended  by  Kossobudskji  is  as  follows  : 

!^  Chrysarobin 0.8 

Iodoform 0.3 

Ext.  bellad 0.6 

Yaselini 15.0 

D.  S.  :  To  be  freely  applied  several  times  daily. 

We  will  not  enumerate  the  numerous  other  salves  which  prob- 
ably act  only  through  the  anaesthetic  drugs  they  contain.  Preis- 
mann ^^  praises  the  action  of  extei'nal  applications  of  iodin-glycerin 
very  highly,  and  gives  the  following : 

^  Kali  iodati 2.00 

lodipuri 0.20 

Glycerini 35.00 

Later  in  the  disease  he  increases  the  strength  of  the  applica- 
tion, thus : 

^  Kali  iodati 5.00 

lodi  puri 1.00 

Glycerini 40.00 

Esmarch's  rectal  support  is  also  to  be  recommended  in  prolapsed 
hemorrhoids  (see  Fig.  46). 

We  must  distinguish  between  "  bloodless  "  and  "  bloody  "  sur- 
gical measures.  The  former  include  stretching  of  the  sphincter, 
particularly  recommended  by  French  authorities  (Yerneuil  and 
others).  It  may  be  carried  out  in  one  or  in  several  sittings  by 
forced  dilatation  with  fenestrated  speculum,  the  blades  being  sepa- 
rated by  a  special  mechanism.     The  same  result  can  be  more  sim- 

*  Log.  cit.,  p.  236. 


DISEASES  OF  THE  RECTUM  5I9 

ply  accomplished  by  passing  two  fingers  into  the  rectum  after  pre- 
vious introduction  of  a  grooved  speculum  and  eversion  of  the  rec- 
tum. The  second  bloodless  method,  used  and  recommended  more 
especially  in  England  and  America,  is  the  fixed  or  elastic  ligature 
(von  Dittel).  As  far  as  I  know,  this  procedure  is  but  little  used  in 
Germany.  Destruction  of  the  nodules  with  fuming  nitric  or  carbolic 
acid  is  also  practiced ;  the  skin  of  the  anal  region  and  tlie  peri- 
neum is  protected  from  the  action  of  the  acid  by  a  thick  coating  of 
vaselin. 

In  1887,  Lange  ^^,  of  New  York,  recommended  local  injections 
of  carbolic  acid  and  glycerin,  in  concentration  of  1 :  5  to  1 : 2.  In 
numerous  cases,  even  of  large  nodules,  this  method  has  proved  suc- 
cessful in  my  hands.     I  usually  proceed  as  follows : 

The  patient  is  told  to  press  out  the  nodules.  For  this  purpose 
it  is  best  to  give  him  a  warm  enema  beforehand,  or  to  have  him 
sit  on  a  bed-chamber  filled  with  hot  water.  The  rectum  and  the 
anus  are  then  carefully  cleansed  with  a  one-half -per-cent  lysol  solu- 
tion. The  skin  about  the  anus  is  smeared  with  borated  vaselin. 
As  an  injection  I  use  fifty-per-cent  carbolic-acid  glycerin,  employ- 
ing an  accurately  graduated  syringe.  The  needle  is  introduced  at 
the  border  of  each  nodule,  about  three  drops  injected  into  each, 
and  the  needle  is  allowed  to  remain  in  situ  for  a  few  minutes. 
After  it  has  been  withdrawn  and  the  parts  again  cleansed,  the  other 
nodules  are  successively  treated  in  the  same  manner.  If  possible, 
the  prolapsed  nodules  are  replaced,  a  large  cotton  pad  and  T-bandage 
applied,  and,  to  produce  constipation,  fifteen  drops  of  the  tincture  of 
opium  and  a  bland  diet  given.  Eest  in  bed  from  two  to  three 
days.  Castor  oil  on  the  third  day.  Limited  activity  for  sev- 
eral days. 

In  only  one  of  my  cases  did  acute  inflammation  follow ;  under 
appropriate  treatment  the  inflammation  soon  disappeared.  All  the 
cures  resulted  without  much  pain.  This  operation  does  not  guard 
against  relapses,  but  it  has  the  great  advantages  of  simplicity  and 
lack  of  danger.* 

The  "bloody"  methods  of  operation  seek  destruction  of  the 
hemorrhoids  by  the  production  of  scar  tissue  by  means  of  either  the 
actual  or  thermo-cautery  [Paquelin],  the  galvano-caustic  loop  (von 
Bardeleben),  or  by  extirpation  of  the  nodules  and  subsequent  suture 

*  Roux^ä  very  appropriately  says  of  this  method:  "Compared  to  the  bloody 
operations  it  has  only  one  disadvantage :  it  is  no  longer  an  art  to  rapidly  and  care- 
fully operate  hemorrhoids." 


520  DISBASES  OP  THE   INTESTINES 

(Whitehead's  operation).  These  are  the  operations  generally  per- 
formed in  Germany ;  they  will  be  found  described  in  surgical  text- 
books. 

LITERATURE 

1.  Jullien.     Beiträge  zur  Dermatologie  u.  Syphilis.     Festschrift  für  G.  Lewin, 

1895. 

2.  Th.  Baer.     Deutsche  med.  Wochenschr.,   1896,  No.  8,  and   1897,  No.  51 

u.  52. 

3.  Bushe.     Cited   by  von  Esmarch,    Die    Krankheiten   d,   Mastdarms  u.  d. 

Afters.     Stuttgart,  1887,  S.  72. 

4.  Quenu  et  Hartmann.     Chirurgie  du  Rectum.     Paris,  1895,  p.  188. 

5.  Allingham.     The   Diagnosis   and   Treatment  of   Diseases  of  the  Rectum, 

p.  269,  sixth  edition,  1896. 

6.  Van  der  Willigen.     Neederl.-Tijdschr.  v.  Geneeskunde,  1893,  i,  No.  17. 

Cited  from  the  Centralbl.  für  Gynäcologie,  1895,  S.  481. 

7.  Conitzer.     Munch,  med.  Wochenschr.,  1899,  No.  3. 

8.  Rieder.     Archiv  f.  klin.  Chirurgie,  1897,  Bd.  Iv,  S.  730. 

9.  Nickel.     Virchow's  Archiv,  Bd.  cxvii,  S.  279. 

10.  Pölchen.     Ibid.,  S,  189. 

11.  Virchow.     Die  krankhaften  Geschwülste,  1864-1865,  Bd.  ii,  S.  416. 

12.  Alderhot.      Beiträge   zur   Kenntniss   der    Rectumsyphilis.      Diss.-Inaug. 

Berlin,  1896. 

13.  Thiem.     Verhandl.  der  deutschen  Gesellschaft  für  Chirurgie,  1893,  Bd.  i, 

S.  49. 

14.  Sonnenburg.     Ibid.,  1897. 

15.  Rotter.     Archiv  f.  klin.  Chirurgie,  Bd.  Iviii,  S.  334. 

16.  Schede.     Verhandl.  d.  deutschen  Gesellschaft  f.  Chirurgie,  1895. 

17.  Bokai.     Krankheiten  des  Mastdarms  u.  des  Afters.     Gerhardt's  Handbuch 

der  Kinderkrankheiten,  vi,  2te  Abth. 

18.  Budin.     Cited  from  Galliard,  Maladies  de  Tintestin.     Traite  de  Medecine, 

t.  iv,  p.  698. 

19.  Nothnagel.     Darmkrankheiten,  S.  469. 

20.  Lannelongue.     Cited  by  Galliard  (see  reference  18). 

21.  Reinbach.     Beiträge  zur  klin.  Chirurgie,  1897,  Bd.  xix,  H.  1. 

22.  Rosenheim.     Die   Pathologie  u.    Therapie    d.    Krankheiten   des   Darmes, 

S.  219. 

23.  Soulier.     Cited  from  Mathieu.     Therapeutique  des  maladies  de  l'intestin, 

second  edition,  p.  91. 

24.  Kossobudskji.     Cited  from  the  Centralbl.  f.  Chirurgie,  1889. 

25.  Macdonald.     Cited  from  the  Wiener  med.  Presse,  1892,  S.  1886. 

26.  Preismann.     Weiner  med.  Presse,  1891,  No.  22. 

27.  Lange.     Verhandl.  der  deutschen  Gesellschaft  f.  Chirurgie,   1887.     Cited 

from  the  Centralbl.  f.  Chirurgie,  1887. 

28.  Roux.     Therapeutische  Monatsh.,  März,  1895. 


CHAPTER  XXI 

NERVOUS  DISEASES   OF  THE  INTESTINES 

Preliminary  Remarks. — In  the  General  Division  (page  34)  we 
have  given  a  brief  and  incomplete  description  of  intestinal  innerva- 
tion. From  this  it  is  seen  with  what  complicated  conditions  we 
must  deal  in  describing  the  pathology  of  intestinal  neuroses. 

The  few  anatomico-pathological  investigations  of  Jürgens  \ 
Blaschko^,  Sasaki^,  Schleimpüug *.  and  Emminghaus^  point  the 
way  to  future  investigators ;  in  themselves  they  are  not  sufficient 
for  clinical  purposes. 

The  uncertainty  of  the  study  of  intestinal  neuroses  is  further  in- 
creased by  the  unstable  transition  between  organic  intestinal  disease 
and  the  so-called  neuroses.  Just  as  cystitis  may  develop  from  vesi- 
cal paralysis  of  spinal  origin,  so  organic  changes  in  the  intestinal 
mucous  membrane  may  arise  from  disturbances  of  intestinal  inner- 
vation. At  certain  stages  we  can  recognise  changes,  but  not  their 
origin.  Disturbances  of  intestinal  innervation  probably  do  not  fol- 
low one  course,  but  secretory-motor  and  vaso-motor  disturbances 
combine. 

Under  conditions  so  little  understood,  our  only  resource  is  clini- 
cal observation  and  experience. 

Like  gastric  neuroses,  intestinal  neuroses  may  be  divided  into 
motor,  sensory,  and  secretory.  There  is  also  a  mixed  or  "  com- 
plex" form  of  intestinal  neurosis,  which  appears  as  general  intes- 
tinal neurasthenia. 

1.    Motor    Neuroses 

{a)  Enterospasm  and  Proctospasm 

While  spastic  conditions  of  the  bowel  are  most  frequent  and 
prominent  in  organic  intestinal  disease  (particularly  stenosis),  entero- 
spasm is  very  seldom  observed  as  a  jpurely  functional  neurosis. 

521 


522  DISEASES   OF   THE  INTESTINES 

J^Jothnagel  ^  denies  its  existence  entirely.  This  seeras  to  me 
somewhat  farfetched,  although  experienced  physicians  must  admit 
the  rarity  of  primary,  spastic  intestinal  contraction.  Few  cases  have 
been  reported,  and  these  (including  the  one  of  Talma  cited  by 
IS^othnagel  *)  are  not  entirely  free  from  objections.  Proctospasm  is 
usually  secondary  to  local  affections  of  the  rectum  or  of  the  pelvic 
organs.  It  is  met  with  as  a  functional  condition  (occasionally  com- 
bined with  anal  crises)  in  tabes  dorsalis,  and  as  a  symptom  of  gen- 
eral hysteria  and  neurasthenia. 

Symptomatology  and  Diagnosis 

The  principal  symptoms  of  enterospasm  are  painful  intestinal 
contractions  which  the  patient  feels,  and  which  are  accompanied 
by  rumbling  and  borborygmi,  and  by  the  passage  of  fragmentary 
scybalse,  with  marked  rectal  tenesmus. 

These  symptoms  generally  occur  at  intervals,  and  are  often 
started  or  increased  by  excitement.  The  following  is  an  example 
of  enterospasm  of  nervous  origin  : 

Miss  H.,  sixty  years  of  age,  has  for  many  years  suffered  from  the  following 
attacks :  Every  four  to  eight  days,  without  apparent  cause,  sxidden  severe  pain 
is  felt  in  the  umbilical  region.  At  the  height  of  the  attack  there  is  an  urgent 
desire  to  defecate.  Three  to  five  times  a  day  she  passes  many  small,  thin  faecal 
masses.     Each  act  of  defecation  is  followed  by  one  or  two  hours  of  ease. 

During  these  attacks  (which  often  last  a  whole  day)  the  patient  is  confined 
to  her  room.  The  abdomen  is  frequently  distended.  Except  for  mild  consti- 
pation, the  patient  is  subjectively  well.  She  ascribes  her  affection  to  overworry. 
The  first  attacks  began  twenty-five  years  ago.  Besides  slight  hemorrhoids,  this 
very  robust  and  well-nourished  woman  presents  no  objective  symptoms. 

In  cases  like  this  the  diagnosis  is  readily  made,  but  where  the 
etiology  is  less  clear  it  may  be  very  difficult  to  distinguish  between 
this  affection  and  organic  stenosis.  The  following  points  are  impor- 
tant :  the  long  duration  of  the  affection,  the  good  general  condition, 
normal  health  in  the  interval  between  attacks,  and  the  presence  of 
neurasthenic  or  hysterical  stigmata. 

The  symptoms  of  proctospasm  consist  of  severe  periodical,  some- 
times almost  unbearable  pain  in  the  rectum,  accompanied  by  sphinc- 
teric  contraction. 

The  following  cases  will  illustrate  and  explain  the  clinical  pic- 
ture of  the  disease : 

*  Loc.  cit.,  p.  463. 


NERVOUS  DISEASES  OF   THE  INTESTINES  523 

I.  (Observation  of  Peyer''.)  Sexual  neurasthenic,  aged  fifty,  suffers  from 
various  severe  neuralgias,  joarticularly  of  the  testicle.  His  proctospasm  shows 
itself  at  first  as  a  marked,  painful  tenesmus  of  the  rectum,  necessitating  an  im- 
mediate attempt  at  defecation,  but  neither  stool  nor  wind  passes.  With  this 
tenesmus  there  is  a  very  severe  spasm  of  the  sphincter,  so  that  the  patient  can- 
not force  even  the  narrow  canula  of  an  irrigating  syringe  into  his  rectum.  Af- 
ter some  time  the  pain  leaves  suddenly  and  radiates  to  the  bladder  or  testicle. 

II.  (Personal  observation.)  Mr.  K.,  merchant  of  Prague,  aged  fifty-two, 
good  family  history,  had  a  mild  attack  of  syphilis  six  years  ago.  Later,  articu- 
lar rheumatism,  which  his  physician  ascribed  to.  the  syphilis.  Irregular  stool 
during  the  confinement  to  bed  necessitated  by  the  rheumatism.  Though  he  gen- 
erally sleeps  well,  and  has  a  good  appetite,  he  has  become  very  nervous  through 
much  overwork.  There  is  constipation,  and  occasionally  mild  tenesmus. 
When  tenesmus  is  severe,  diarrhoea  ensues  ;  normal,  cylindrical  stool  is  very 
rare. 

During  the  last  few  years  he  suffers  from  anal  spasms  every  two  or  three 
"days,  and  more  recently  every  three  to  five  days.  These  generally  come  on  at 
night.  The  patient  is  suddenly  awakened  by  severe  pain,  as  if  the  sphincter 
ani  were  spasmodically  drawing  itself  together.  The  finger  can  be  introduced 
only  with  great  difficulty.  The  spasm  may  be  controlled  by  the  successive 
introduction  of  the  larger  fingers.  In  a  few  minutes  the  entire  attack  ceases. 
The  proctospasm  is  generally  preceded  by  constipation,  and  never  occurs  after 
satisfactory  defecation. 

In  the  interval  between  attacks  the  calibre  of  the  rectum  is  normal.  No 
symptoms  of  tabes.* 

The  diagnosis  of  proctospasm  is  not  difficult.  In  order  to  estab- 
lish the  nervous  character  of  the  disease  it  is  always  necessary  to 
make  a  rectal  or  vaginal  examination. 

Treatment 

Where  appreciable  lesions  of  the  rectum  or  genitals  exist,  or 
v^^here  the  symptoms  are  produced  by  spinal  disease,  appropriate 
measures  must  be  apphed.  In  purely  functional  entero-  and  procto- 
spasm it  will  be  necessary  to  treat  the  underlying  nervous  basis  of 
the  disease.  For  this  purpose  cold  hydrotherapeutic  measures,  ene- 
mata  (perhaps  with  the  rectal  cooler),  mild  galvanization  of  the  rec- 
tum and  abdomen,  and  systematic  passing  of  elastic  bougies  are  best. 
The  attack  may  be  checked  by  bromids,  or  by  opium,  morphin, 
belladonna,  codein,  and  cocain,  internally  or  in  suppositories.  Con- 
stipation, if  present,  should  be  treated  dietetically,  with  or  without 
the  addition  of  mild  purgatives  and  enemata. 

*  We  must  always  remember  the  possibility  of  this  being  an  initial  symptom  of 
tabes,  which,  analogous  to  gastric  crises,  may  antedate  the  ataxia  by  many  years. 


524  DISEASES   OF   THE  INTESTINES 

{b)  Peristaltic  Restlessness  {Tormina  Intestinorum  Nervosa) 

KussmauP,  in  18T8,  was  tlie  first  to  call  attention  to  the  occur- 
rence of  visible  peristalsis  of  ttie  stomach  and  intestine  in  neuro- 
pathic individuals.  These  contractions  may  affect  stomach  and 
intestines  together  or  each  separately.  They  occur  in  paroxysms,, 
particularly  after  nervous  excitement.  They  are  usually  observed 
in  women  with  flabby  abdominal  walls  and  enteroptosis.  Peyer'^  has 
observed  several  cases  in  male  sexual  neurasthenics. 

St:mptomatologt  A2sd  Diagnosis 

The  chief  symptoms  are  a  feeling  of  movement  and  of  drawing 
together  in  the  abdomen,  which  may  increase  to  spasmodic  pain. 
In  marked  cases  there  may  be  simultaneous  rumbling  sounds.  These 
attacks  are  independent  of  the  time  of  food  ingestion,  but  may  be 
visibly  increased  by  certain  agents — carbonated  beverages,  laxa- 
tives, etc.  They  frequently  occur  at  night,  and  deprive  the  patient 
of  sleep. 

On  inspection,  the  lively  peristaltic  wavelike  motion  of  the 
intestine  is  usually  immediately  apparent.  Where  the  j)icture  is 
not  well  defined,  hyperperistalsis  may  be  induced  by  abdominal 
friction,  pouring  ether  upon  the  abdomen,  faradism,  and  distention 
of  the  stomach  or  intestine  with  air  or  carbonic  acid.  The  peristal- 
sis mainly  involves  the  small  intestine,  but,  as  shown  by  the  case 
described  below,  the  large  intestine  may  also  be  affected.  Noth- 
nagel^ maintains  that  evacuations  always  accom]j)any  the  latter 
condition.  In  my  case  this  was  not  so ;  the  patient  always  had 
normal  stool. 

The  attacks  vary  considerably  in  intensity  and  duration.  In  the 
same  individual  I  have  sometimes  seen  mild  peristalsis  last  for  hom-s, 
and  violent  actions  decrease  after  a  few  minutes. 

In  my  work  on  Diseases  of  the  Stomach  (Part  II,  third  edition, 
p.  236)  I  have  described  a  case  of  this  kind.  I  demonstrated  a 
second  much  more  typical  patient  at  the  Congress  for  Internal 
Medicine^.     As  the  latter  case  is  very  interesting  I  repeat  it  here: 

Pauline  R.,  sixty  years  old,  peasant's  wife,  has  had  considerable  trouble 
and  worry  throughout  her  life.  Her  father,  a  teacher,  suffered  from  nervous- 
ness during  the  last  few  years  of  his  life,  and  committed  suicide  in  his  fifty- 
second  year.  Patient  has  a  brother  who  is  quite  well.  No  other  sickness  in 
the  family. 

Patient  herself,  when  a  young  girl,  was  always  anaemic,  and  had  "liver 


NERVOUS  DISEASES   OF   THE  INTESTINES  525 

trouble,"  but  was  never  confined  to  bed,  and  never  had  jaundice.  Present  ill- 
ness began  about  eight  years  ago,  when,  after  passing  through  a  severe  illness 
and  after  the  death  of  her  husband,  she  spent  many  weeks  in  mental  suffering. 
Her  syrüptoms  then  consisted  of  an  occasional  wavelike  motion  in  the  ciMomen, 
which  disappeared  whenever  she  felt  contented  or  happjy. 

The  death  of  her  only  son  aggravated  her  condition.  Since  then  (three 
years)  her  condition  has  remained  about  the  same.  She  is  sometimes  entirely 
well  for  weeks  and  months,  then,  generally  after  some  psychic  disturbance,  she 
suffers  for  days  or  weeks.  Since  March  of  this  year  the  symptoms  are  almost 
continuous-,  this  she  ascribes  to  the  severe  illness  of  her  son-in-law. 

She  complains  of  a  feeling  as  of  a  dead  weight  in  the  abdomen  and  a  wave- 
like sensation,  which  occur  usually  at  night.  The  attacks  are  independent  of 
work,  and  are  frequently  relieved  by  eating.  Appetite  good;  bowels  regular. 
Patient  does  not  otherwise  feel  ill.     Has  had  five  children ;  no  miscarriages. 

Status  prcEsens. — Frail  woman,  good  colour,  poorly  developed  muscular  sys- 
tem and  fat.  Pupils  react  well  to  light,  but  not  so  well  to  accommodation. 
Triceps  and  patellar  reflexes  cannot  be  elicited.  Skin  reflexes  markedly  dimin- 
ished. Lungs  and  heart  normal.  Abdomen  is  hemispherically  distended,  the 
greatest  prominence  ajjpearing  below  the  umbilicus.  When  the  patient  raises 
the  upper  portion  of  her  body  the  intestines  press  forward  through  a  broad  dias- 
tasis of  the  recti  muscles,  which  reaches  from  the  umbilicus  to  the  symphysis. 
Abdominal  walls  are  thin  and  flabby. 

Liver:  Upj)er  border  begins  at  the  seventh  rib  in  the  mammary  line.  As 
determined  by  paljiation  and  percussion,  the  lower  border  of  the  liver  corre- 
sponds to  a  line  beginning  two  fingerbreadths  above  the  right  anterior  inferior 
spine  of  the  ilium,  passing  through  the  umbilicus,  and  reaching  the  eighth  left 
costal  cartilage.  Above  this  line  there  is  uniform  dulness.  The  sharp  border 
of  the  liver  may  be  jilainly  felt  in  the  right  half  of  this  line,  less  so  in  the  left 
half.  The  spleen  is  slightly  movable,  and  its  border  may  be  felt  in  the  left 
hypochondrium. 

Kidneys  are  palpable. 

As  determined  by  palpation  of  an  introduced  sound,  distention,  and  trans- 
illumination in  the  fasting  condition,  the  greater  curvature  of  the  stomach 
extends  a  handbreadth  below  the  umbilicus.  During  fasting  the  stomach  is 
empty.  Test  breakfast  shows  normal  gastric  functions.  The  urine  contains 
no  albumin,  sugar,  or  indican.  Microscopical  and  macroscopical  examination 
of  the  stools  shows  no  changes. 

Through  the  thin,  flabby  abdominal  walls  one  can  plainly  see  the  peri- 
staltic movements  (Fig.  47).  Three  types  may  be  distinguished ;  they  vary  in 
position,  form,  and  course. 

During  rest,  one  sees  two  or  three  parallel  sausage-shaped  protuberances 
lying  quite  closely  together.  These  periods  of  rest  last  but  a  very  short  time. 
Soon  each  protuberance  is  seen  to  contract  at  one  end.  The  wave  of  contraction 
passes  along  the  entire  segment,  while  behind  it  the  protuberance  again  reforms. 
The  whole  action  is  slow  and  vermicular.  There  is  a  continuous  alternation  of 
contraction  and  protuberance,  and,  following  the  simile  of  Nothnagel,  the  sur- 
face of  the  abdomen  may  be  compared  to  that  of  a  bag  filled  with  potatoes. 

In  the  left  side  of  the  abdomen,  from  the  free  border  of  the  ribs  to  about 


526 


DISEASES   OF   THE  INTESTINES 


the  anterior  superior  iliac  spine,  five — occasionally  six — parallel  swellings,  each 
about  the  thickness  of  a  stout  lead  pencil,  may  be  seen.  They  are  somewhat 
farther  apart  than  the  sausage-shaped  tumours  before  described,  and  approxi- 
mately one  half  the  length  of  the  latter  (about  4  to  5  centimetres).  Several 
of  these  swellings  disappear  and  reappear  one  after  the  other,  thus  giving 
the  impression  as  of  the  whole  mass  suddenly  springing  forward  ("harmonica 
motion ").  Seemingly  independent  of  the  motions  just  described,  a  line  of 
shadow  passes  about  midway  between  these  tumours,  oscillating  from  left  to 
right  and  mce  versa. 

In  the  epigastrium  a  semicircular  arching  may  be  seen,  the  lower  border 
corresponding  exactly  to  the  greater  curvature  of  the  stomach.  Along  this 
border  a  deep  contraction  passes  from  left  to  right,  and  is  immediately  suc- 


Fig.  47. — Peeistaltic  Eestlessness  of  the   Small  Intestines  and  Descending  Colon. 

(Original  observation.) 


ceeded  by  a  protrusion.  One  or  two  flngerbreadths  below  the  liver  the  con- 
traction continues  somewhat  longer,  so  that  we  see  two  protrusions  separated 
by  a  depression ;  from  this  point  the  contraction  again  takes  place  more  ener- 
getically, till  the  line  of  liver  dulness  is  reached.  The  series  then  begins  anew 
and  continues  uninterruptedly.  The  direction  of  motion  is  always  from  left  to 
right.     Each  series  lasts  from  fifteen  to  eighteen  seconds. 

The  patient  does  not  feel  these  motions.  Throughout  the  examinations  she 
has  pain  only  when  the  peristalsis  becomes  severe.  A  pulsation  can  also  be  seen; 
it  may  be  mistaken  for  peristalsis.     The  pulsation  evidently  originates  in  the 


NERVOUS  DISEASES   OF   THE  INTESTINES  527 

great  arterial  trunks,  and  is  transmitted  through  the  flabby  abdominal  walls. 
It  can  be  seen,  and  not  felt,  and  is  synchronous  with  the  radial  pulse. 

These  peristaltic  movements  may  be  increased  to  a  slight  extent  by  faradi- 
zation, friction,  and  cooling  the  abdomen. 

The  diagnosis  of  the  condition  is  not  difficult.  We  must  always 
consider  the  possibility  of  intestinal  stenosis  or  partial  adhesions. 
Several  years  ago  I  observed  a  large,  fixed  umbilical  hernia  com- 
plicated by  hyperperistalsis.  The  condition  of  the  general  nervous 
system,  the  alternate  disappeai-ance  and  reappearance  of  the  peri- 
staltic movements,  and  its  dependence  upon  excitement,  are  useful 
diagnostic  facts. 

Teeatment  , 

We  must  first  attempt  to  strengthen  the  general  nervous  sys- 
tem through  appropriate  climatic  and  hydrotherapeutic  measures. 
Kussmaul  has  achieved  good  results  from  the  intragastric  and  ex- 
ternal use  of  the  faradic  current. 

Internally,  we  may  give  the  alkaline  bromid  salts,  narcotics,  and 
perhaps  also  antipyretics  (antipyrin,  phenacetin,  lactophenin,  etc.). 
In  one  case  I  saw  good  results  from  codein  and  belladonna.  Rosen- 
heim ^°  recommends  chloral  hydrate  (1  gram,  evenings,  in  gruel). 

In  the  case  described  the  attacks  ceased  when  the  patient  was 
admitted  to  my  private  clinic  for  closer  observation.  Bodily  and 
mental  rest  and  appropriate  nursing  evidently  contributed  consider- 
ably to  this  favourable  result. 

(c)  Paresis  {Ato7iy)  and  Paralysis  of  the  Intestines 

Paresis  or  atony  of  the  intestines  ("  intestinal  insufficiency," 
O.  Eosenbach)  is  a  functional  debility  of  the  intestinal  muscular 
system  ;  paralysis  is  an  absolute  loss  of  the  motor  power  of  the 
intestines.  Both  conditions  affect  the  large  bowel  only.  Pareses 
of  the  muscle  of  the  small  bowel  are  unknown.  In  the  chapter  on 
Intestinal  Strictures  and  Intestinal  Obstruction  we  have  described 
paralytic  conditions  of  mechanical  origin.  In  what  follows  we  shall 
discuss  only  their  functional  phases. 

(1)  Atony  op  the  Large  Intestine 

This  is  closely  related  to  and  as  frequent  as  constipation.  All 
the  factors  which  produce  constipation  may  in  time  produce  flabbi- 
ness  or  muscular  fatigue  of  the  bowel,  and,  as  a  result,  partial  or 
general  distention,  or  even  actual  dilatation  of  the  intestine.     Con- 


528  DISEASES  OF  THE  INTESTINES 

stipation  is  here  the  primary  factor.  Much  more  difficult  is  the 
determination  of  other  conditions  which  produce  primary  paresis 
of  the  nervous  muscular  apparatus.  By  the  previously  described 
experiments  of  Emminghaus,  it  was  shown  for  the  first  time  that 
degenerative  processes  of  the  splanchnic  nerve  may  produce  consti- 
pation ;  this  constipation  must  be  considered  as  an  example  of 
neuropathic  intestinal  atony.  The  artificial  or  toxic  intestinal 
pareses  following  the  use  of  opium,  morphin,  and  belladonna  must 
be  placed  in  the  same  category.  In  a  case  under  my  own  observa- 
tion, a  woman  who  within  a  few  weeks  had  taken  more  than  one 
kilogram  [2.2  pounds]  of  bismuth  for  symptoms  resembling  gastric 
ulcer,  there  developed  most  marked  intestinal  paresis  and  dilatation. 
It  is  well  known  that  individuals  who  suffer  from  neuroses  and 
psychic  disturbances  (neurasthenia,  melancholia,  hysteria,  hypochon- 
dria, etc.)  frequently  develop  paretic  or  subparetic  conditions  of 
the  intestinal  muscular  apparatus.  Thus,  in  persons  predisposed  to 
habitual  constipation,  I  have  occasionally  observed  acute  intestinal 
paralyses  from  sudden  fear,  anger,  or  other  excitement.  We  may 
explain  these  phenomena  by  reflex  irritation  of  the  nerves  tliat  in- 
hibit intestinal  peristalsis  (splanchnics).  In  view  of  analogous  con- 
ditions in  the  stomach,  we  must  also  admit  that  traumatism  and 
shock  may  produce  an  inhibitory  action  upon  the  motor  apparatus 
of  the  large  intestine.  Congenital  atony  of  the  intestine  has  also 
been  observed.  Intestinal  paresis  may  result  from  the  continuous 
use  of  large  rectal  enemata. 

Clinical  observation  has  led  to  the  differentiation  between  gen- 
eral and  partial  atony.  In  a  series  of  articles  Federn  ^^  has  called 
attention  to  the  latter  condition.  According  to  this  author,  partial 
atony  plays  a  large  part  in  general  pathology.  He  finds  this  condi- 
tion not  alone  in  intestinal  diseases,  but  also  in  arterio-sclerosis,  car- 
diac asthma,  pulmonary  tuberculosis,  neurasthenia  and  hysteria,  and 
Basedow's  disease.  Federn  even  states  that  partial  intestinal  atony 
is  connected  with  the  development  of  the  last-named  disease.  He 
maintains  that  the  diagnosis  of  partial  atony  can  be  made  from  the 
strikingly  pungent  smell  of  the  stools,  and  from  the  fact  that  gentle 
percussion  of  the  intestines  elicits  dulness  over  some-  areas,  while 
deep  percussion  of  the  same  areas  elicits  a  tympanitic  percussion 
note. 

It  needs  no  special  demonstration  to  prove  how  little  defined 
and  characteristic  are  the  symptoms  described  by  Federn.  ISTever- 
theless,  there  is  a  grain  of  truth  in  Federn's  observations,  a  truth 


NERVOUS  DISEASES  OF  THE  INTESTINES  529 

of  which  experienced  physicians  have  not  been  as  ignorant  as  this 
author  would  have  us  beheve.  At  several  j)laces  along  the  intes- 
tines, as  the  result  of  faecal  stagnation,  partial  ballooning  may  de- 
velop, and  despite  the  presence  of  diarrhoea  (stercoraceous  diar- 
rhceas),  fsecal  stagnation  may  exist.  As  is  well  known,  the  sites  of 
predilection  for  faecal  accumulations  are  the  csecum,  the  hepatic  and 
splenic  flexures,  the  sigmoid  flexure,  and  the  ampulla  of  the  rectum. 
M.  Herz  ^^  has  recently  directed  attention  to  a  further  type  of 
intestinal  insufiiciency — that  of  the  ileo-csecal  valve,  l^ormally,  the 
large  intestine  is  shut  off  from  the  ileum  by  this  valve.  From  in- 
flammation or  by  flattening  of  its  lower  fold  there  may  result  a 
relative  insufiiciency  of  the  valve,  as  shown  by  tympanites,  consti- 
pation, flatulency,  and  neurasthenic  and  other  nervous  symptoms. 

Symptomatology  and  Diagnosis 

These  have  in  greater  part  been  described  in  the  chapters  on 
Habitual  Constipation  and  Chronic  Enteritis.  Atony  is  frequently 
associated  with  the  latter  condition. 

Atony  is  most  easily  demonstrated  by  the  method  described  in 
the  General  Division  of  this  work  (page  74).  It  consists  in  the 
injection  of  measured  quantities  of  water  per  rectum  and  the  elicit- 
ing of  splashing  sounds  in  the  corresponding  segments  of  the  large 
intestine.  Upon  distending  with  air,  we  find  that  the  amount  re- 
quired is  far  above  the  normal ;  this  also  speaks  for  abnormal  flab- 
biness  of  the  intestine.  Herz  believes  that  proof  of  ileo-csecal 
insufficiency  is  demonstrated  when  gas  under  pressure  can  be  forced 
from  the  csecum  into  the  ileum.  The  changes  in  the  percussion 
note  are  best  obtained  by  percussing  with  the  edge  of  the  finger- 
nail of  one  hand  upon  the  nail  surface  of  the  other. 

The  clinical  aspect  of  diifuse  atony  is  so  characteristic,  that 
its  diagnosis  will  rarely  be  difficult.  In  every  case,  however, 
we  should  think  of  the  possibility  of  an  underlying  mechanical 
cause. 

As  long  as  we  have  no  more  definite  data  than  that  obtained 
from  percussion,  we  shall  not  be  able  to  diagnose  partial  intestinal 
atony. 

Treatment 

This  is  identical  with  that  described  under  Habitual  Constipa- 
tion and  Chronic  Enteritis  {q.  v.).  It  is  unnecessary  to  repeat  the 
detailed  regulations  there  given.     In  ileo-csecal  insufficiency,  Herz 


530  DISEASES   OP  THE  INTESTINES 

recommends  massage  of  the  large  bowel.     In  partial  atony,  besides 
massage,  Federn  advises  faradization  of  the  large  intestine. 

(2)  Paresis  and  Paralysis  of  the  Rectum 

In  describing  paralytic  ileus  (page  403)  we  also  discussed  paral- 
ysis of  the  large  intestine.  It  still  remains  to  describe  paresis  of 
the  rectum. 

Chronic  paresis  of  the  rectum  generally  results  from  local  rectal 
affections  (prolapse,  tumours,  proctitis,  hemorrhoids,  etc.),  but  occurs 
also  as  a  symptom  of  some  spinal  and  cerebral  lesions  (locomotor 
ataxia,  progressive  paralysis,  myelitis,  etc.).  Straining  during  defe- 
cation and  urination  in  prostatic  hypertrophy  and  stricture  of  the 
urethra  may  likewise  produce  rectal  paralysis.  As  a  purely  neurotic 
affection  this  condition  is  extremely  rare.  I  have  once  seen  it  in 
a  boy  of  nine  years  who  was  convalescing  from  diphtheria. 

Several  degrees  of  rectal  paralysis  are  met  with.  In  mild  cases 
the  rectum  is  only  relatively  incontinent ;  in  the  severe  it  is  abso- 
lutely so. 

Symptomatology  and  Diagnosis 

The  main  symptom  is  loss  of  voluntary  control  of  evacuations. 
In  mild  cases  the  sphincter  is  incontinent  only  when  there  is  diar- 
rhoea; in  the  severe,  formed  stools  are  also  involuntarily  passed. 
Active  movements  of  the  body,  slight  straining  of  the  abdominal 
muscles,  coughing,  laughing,  and  sneezing  may  cause  involuntary 
evacuations  and  thus  distress  the  patient. 

The  diagnosis  can  at  once  be  made  by  digital  examination  of 
the  rectum.  The  question  of  etiology  is  more  difficult.  We  must 
search  for  not  only  disease  of  the  rectum  and  of  intestinal  segments 
higher  up,  but  also  for  spinal  disease.  As  shown  by  the  following 
history,  it  may  not  be  easy  to  arrive  at  the  proper  explanation  of 
some  of  these  cases. 

F.  S.,  aged  twenty-two  years,  book  gilder,  has  lost  control  over  his  stools 
for  the  last  two  years.  As  soon  as  there  is  a  desire  to  defecate,  no  matter 
whether  the  stools  be  solid  or  fluid,  an  involuntary  evacuation  immediately  fol- 
lows. The  patient  also  complains  about  urination;  he  must  wait  some  little 
time  before  the  urine  begins  to  flow.  The  act  of  urination  is  normal  and  does 
not  indicate  stricture.     Denies  gonorrhcBa  and  other  sexual  diseases. 

Patient  works  considerably  with  metallic  dust  which  does  not  contain  lead. 

Status  Praesens. — Healthy-looking  young  man;  internal  organs  normal. 
Anus  very  flabby,  readily  admitting  two  fingers.  Proctoscopy  shows  nothing 
special.     Patellar  reflexes  markedly  increased;    no  disturbance  of  sensibility. 


NERVOUS  DISEASES  OF   THE   INTESTINES  531 

The  diagnosis  of  beginning  spinal  lesion  was  made.  This  was  concurred  in  by 
Professor  Oppenheim,  who,  in  view  of  the  intact  sensibility,  diagnosticated  a 
lesion  in  the  motor  centres  of  the  bladder  and  rectum. 

Tkeatment 

Where  the  rectal  paresis  is  secondary,  treatment  must  be  directed 
toward  the  underlying  cause.  Where  this  is  impossible,  or  where  a 
primary  neurosis  is  present,  we  should  endeavour  to  imjDrove  the 
functions  of  the  incompetent  sphincter.  For  this  purpose,  faradiza- 
tion of  the  rectum  is  of  the  first  importance,  and  must  be  carried 
out  thoroughly  and  systematically.  The  diet  should  vary  with  the 
degree  of  the  paralysis. 

If  involuntary  evacuations  occur  only  when  there  is  diarrhoea, 
the  latter  must  be  prevented  by  suitable  dietetic  regulations  (astrin- 
gent diet).  If  involuntary  evacuations  occur  when  the  stools  are 
well  formed,  we  must  prevent  faecal  accumulation  in  the  lower 
intestinal  segment.  By  diet  we  should  attempt  to  have  the  stools 
semisolid,  so  that  a  complete  daily  evacuation  follows.  The  patient 
must  be  particularly  impressed  with  the  importance  of  attending  to 
defecation  regularly,  at  a  certain  fixed  time  of  the  day. 

Where,  despite  these  precautions,  fseces  accumulate  in  the  rec- 
tum, they  should  be  got  rid  of  by  enemata  of  oil  or  soap  water. 
The  diseased  region  should  also  be  stimulated  by  cold  sitz  baths 
and  frequent  irrigations.  Of  medicinal  remedies,  injections  of 
strychnin  (0.001  to  0.002  gram  per  dose),  or  suppositories  of  nux 
vomica  (0.03  gram  twice  a  day)  are  best. 

{d)  Nervous  Flatulence 

This  consists  of  alternating  expulsion  from  and  reaccumulation 
of  air  within  the  bowel,  similar  to  nervous  eructation.  It  is  seen 
mostly  in  hysterical  girls  and  women  and  in  neurasthenics,  but  also 
occurs  in  healthy  individuals. 

The  aifection  may  be  acute,  chronic,  or  periodical.  As  yet  it  is 
but  little  understood.  The  best  theory  is  that  which  attributes  it 
to  rhythmical  contraction  and  dilatation  of  the  intestine.  Anal- 
ogous to  what  Oser  believes  to  take  place  in  nervous  eructation, 
after  the  air  has  been  expelled  from  the  lower  bowel,  renewed  con- 
tractions draw  more  air  from  the  upper  segments  ;  this  leads  to  dilata- 
tion, and  when  the  bowel  is  quite  distended  the  air  is  expressed, 
etc.  In  well-marked  cases  the  expressed  air  is  odourless,  or  only 
slightly  mixed  with  offensive  gases. 


532  DISBASES  OP   THE  INTESTINES 


Symptomatology  and  Diagnosis 

A  feeling  of  tension  and  pressure  predominates ;  this  may 
increase  to  severe  colicky  pain.  Occasionally  the  air  is  heard  rum- 
bling through  the  gut.  The  abdomen  may  be  more  or  less  dis- 
tended ;  in  my  cases,  however,  despite  repeated  complaints  of  the 
accumulation  and  passing  of  air,  abdominal  distention  was  scarcely 
appreciable.  Passing  of  wind  affords  but  little  relief.  Gases  reac- 
cumulate,  and  the  patients  are  disturbed  throughout  the  day  and 
sometimes  at  night.  The  symptoms  are  aggravated  by  mental  dis- 
turbances. 

The  diagnosis  is  made  from  the  clinical  phenomena,  the  course 
of  the  affection,  and  the  negative  abdominal  symptoms. 

Treatment 

This  should  be  directed  toward  the  underlying  hysterical  or 
neurasthenic  basis.  The  forbidding  of  foods  which  produce  flatu- 
lency is  usually  ineffectual.  Since  the  patients  are  generally  poorly 
nourished,  anemic  individuals,  a  mixed  diet  rich  in  fats  is  espe- 
cially beneficial.  Fluids  and  soups  should  be  avoided,  since  they 
often  increase  the  flatulence  and  the  feeling  of  weight  in  the  stom- 
ach and  intestine.  Warmth,  both  internal  (valerian,  peppermint, 
and  caraway  teas)  and  external  (warm  fomentations),  brings  relief 
and  quiets  the  excited  peristalsis.  Of  the  many  remedies  recom- 
mended for  nervous  flatulence,  the  best  are  the  nux  vomica  prep- 
arations (extract  of  nux  vomica,  0.01  to  0.03  gram  per  dose,  in 
powder  or  pills),  or  extract  of  Calabar  bean  (0.05  gram  to  10.00  of 
glycerin,  5  to  6  drops  t.  i.  d.,  or  pills,  0.005  to  0.01  gram  per  dose). 

Where  constipation  coexists,  diet  and  the  magnesia  preparations 
(especially  magnesia  usta)  are  to  be  recommended. 

2.  Sensory  Neuroses 

Enteralgia  {Neuralgia  Plexus  Mesenterici) 

This  is  a  periodic,  painful  irritation  of  the  intestinal  nerves, 
occurring  without  apparent  anatomical  cause.  Thus  enteralgia  is  a 
true  neuralgia,  and,  as  stated  by  Nothnagel,*  must  be  distinguished 
from  the  colic  of  intestinal  contraction.  The  cause  is  said  to  be  in 
the   large   nerve    plexuses   (mesenteric,    hypogastric,    and   coeliac). 

*  Loc.  cit.,  p.  489. 


NERVOUS  DISEASES  OP  THE   INTESTINES  533 

Eomberg  has  tried  to  establisli  separate  types  of  the  affection  for 
the  different  plexuses  affected.  When  carefully  examined,  how- 
ever, the  symptoms  are  so  similar  that  it  is  almost  impossible  to 
differentiate  these  groups.  The  very  assumption  that  enteralgia 
is  due  to  disease  of  the  mesenteric  plexus  is  purely  theoretical. 
Malaria,  lead  poisoning,  and  locomotor  ataxia  are  cited  as  causes  of 
entei'algia.  This  condition  is  also  found  in  hysterical  and  neuras- 
thenic individuals,  and  Peyer  has  very  often  observed  it  in  sexual 
neurasthenics. 

S  TMPTOM  ATOLOGT 

Enteralgia  presents  itself  as  mild  or  severe,  drawing,  cutting, 
boring,  and  burning  pains  in  the  abdomen,  particularly  in  the  meso- 
gastrium.  The  patients  take  to  bed,  writhe  with  pain,  and  seek 
relief  by  evacuations  or  the  passing  of  wind.  In  severe  cases  vomit- 
ing  may  occur  and  afford  the  patient  temporary  relief. 

We  shall  not  discuss  in  detail  the  enteric  crises  of  locomotor 
ataxia,  but  mention  that  they  constitute  the  purest  and  most  instruc- 
tive types  of  enteralgia. 

The  attacks  may  cease  after  several  minutes,  or,  with  slight 
remissions,  last  for  hours  or  days  (as  in  visceral  crises).  They  gen- 
erally cease  or  become  less  acute  during  the  night. 

In  one  of  my  patients,  a  man  of  fifty,  whose  nervous  system  was  upset  by 
intense  excitement,  severe  pain  followed  each  act  of  an  otherwise  normal  defe- 
cation. Careful  clinical  examination  showed  normal  intestinal  functions  and 
stools. 

Galvanism  improved  his  condition,  and  a  sojourn  in  the  mountains  entirely 
cured  him. 

Ohjectively,  there  may  be  slight  tympanitis  and  local  points  of 
pain,  particularly  in  both  hypochondria  (A.  Peyer).  According  to 
my  experience,  the  severe  pain  complained  of  is  in  marked  contrast 
with  the  normal  condition  of  the  abdomen. 

Constipation  may  accompany  enteralgia,  but,  unlike  stercora- 
ceous  colic,  does  not  constitute  a  necessary  feature  of  the  attack. 
That  constipation  accompanies  enteralgia  of  longer  duration  (e.  g., 
enteric  crises)  is  explained  by  the  vomiting  usually  present,  and  the 
abstinence  from  food. 

The  diagnosis  of  enteralgia  is  easily  made  when  its  etiology  is 
apparent  (e.  g.,  locomotor  ataxia,  arthritis,   lead   intoxication,  hys- 
teria, and  neurasthenia).    When  the  etiology  cannot  be  discovered 
the  diagnosis  is  always  uncertain. 
35 


534  DISEASES  OP  THE  INTESTINES 

Hepatic,  renal,  and  cystic  calculi  must  first  be  carefully  excluded. 
An  irregular  cholelithiasis  may  closely  resemble  enteralgia.  Care- 
ful examinations  of  the  anterior  and  posterior  regions  of  the  liver, 
questioning  regarding  icterus,  and  the  finding  of  concretions  may 
aid  in  the  differentiation.  In  distinguishing  from  nephrolithiasis 
and  cystolithiasis,  we  must  consider  the  data  obtained  from  palpa- 
tion of  the  kidney  and  bladder,  examination  of  the  urine,  and  cys- 
toscopy. Enteralgia  can  usually  be  distinguished  from  flatulent  colic 
by  the  presence  of  f  secal  accumulations,  or  by  the  irregular  char- 
acter of  the  stools  in  the  latter  and  by  the  cessation  of  the  attack 
when  large  quantities  of  flatus  have  been  passed. 

Differentiation  from  true  colitis  can  generally  be  made  by  re- 
peated and  careful  inspection  of  the  stools  and  by  intestinal  irriga- 
tion. In  this  connection  we  would  mention  hernias  of  the  linea  alba, 
which  are  easily  overlooked,  and  which  often  cause  gastralgia  or 
enteralgia.  Adhesions  of  the  intestinal  segments  may  produce  all 
the  symptoms  of  severe  intestinal  neuralgia. 

In  some  text-books  (Rosenheim  and  A.  Pick)  peritonitis  and 
perityphlitis  (A.  Peyer)  are  also  considered  in  this  connection. 
When  the  patient  is  examined  not  only  during  the  attack  but  also 
after  its  completion,  error  is  almost  impossible. 

Tkeatment 

■  As  enteralgia  is  not  a  primary  affection,  its  curability  depends 
upon  the  underlying  disease.  In  lead  colic,  complete  cure  is  ac- 
complished by  removal  of  the  toxic  cause  and  by  the  administra- 
tion of  appropriate  remedies  (iodin  preparations,  sulphur  baths, 
etc.).  Up  to  the  present  time  the  visceral  crises  of  locomotor  ataxia 
have  remained  rebellious  to  treatment.  The  crises  of  gout  are  like- 
wise extremely  obstinate.  In  these  latter  instances,  as  well  as  in 
idiopathic  enteralgia,  we  must  treat  the  paroxysms  symptomatically 
with  hot  fomentations,  warm  enemata,  and  narcotics  (best  subcuta- 
neously  or  in  suppositories).  Invigorating  general  treatment  is  in- 
dicated in  neurasthenical  or  hysterical  enteralgias.  Galvanization 
of  the  abdomen  and  rectum  may  also  be  tried. 

3.   Secretory  Neuroses 

(«)  Nervous  Diarrlioßa 

This  condition,  first  minutely  described  by  Trousseau,  is  charac- 
terized by  more  or  less  numerous  thin,  watery,  generally  periodic 


NERVOUS  DISBASES  OF  THE  INTESTINES  535 

evacuations.  The  diarrhoea  may  result  from  some  ceutral  disturb- 
ance (the  irritation  being  carried  along  the  course  of  the  vagi  and 
sympathetic),  from  peripheral  irritation  (alimentar}'^  diarrhoea),  it 
may  be  reflex  (disease  or  displacement  of  the  genital  organs,  en- 
tozoa,  thermic  causes,  etc.),  or  may  be  due  to  the  absorption  of  toxic 
products. 

In  a  limited  sense,  nervous  diarrhcea  is  usually  an  accompany- 
ing symptom  of  general  nervous  debility.  This  fact  must  be  kept 
in  mind,  since  only  by  its  careful  consideration  can  a  positive  diag- 
nosis be  made  and  favourable  treatment  instituted.  A  more  ex- 
tended experience  enables  us  to  distinguish  several  types :  The  first 
group  is  characterized  by  the  fact  that  under  the  influence  of  emo- 
tions, or  after  partaking  of  certain  food  or  drink,  these  individuals, 
whose  intestinal  functions  are  otherwise  normal,  suddenly  have  one 
or  several  quickly  repeated  fluid  evacuations. 

In  the  second  group  the  intestines  are  unstable,  a  tendency  to 
diarrhcea  exists,  but  the  patients  are  otherwise  healthy.  From 
mental  excitement  or  variations  from  their  ordinary  mode  of  liv- 
ing, sudden  severe  diarrhoeal  evacuations  occur,  which  cease  after 
the  patient  is  placed  under  normal  conditions. 

A  third  group  is  characterized  by  diarrhoea  under  special  condi- 
tions—for example,  when  opportunity  for  defecation  does  not  exist, 
or  is  surrounded  by  certain  embarrassing  difiiculties.  At  other 
times  the  intestinal  function  is  normal. 

Symptomatology  and  Diagnosis 

Apart  from  the  etiology  and  the  periodicity  of  its  occurrence, 
nervous  diarrhoea  presents  no  specific  features.  The  number  of 
dejections  varies  largely.  The  subjective  symptoms  are  the  usual 
ones  of  tenesmus,  rumbling,  severe  thirst,  etc.  The  stools  are  not 
characteristic.  The  patients  tell  us  that  food  has  been  passed  com- 
pletely undigested,  but  since  there  is  rarely  an  opportunity  for  ex- 
amining the  stools  during  an  attack  this  statement  must  be  accepted 
with  great  reserve.  We  shall  again  refer  to  the  question  of  mucous 
admixture  of  the  evacuations.  Blood  is  never  or  very  exceptionally 
present.     Pus  is  always  absent. 

These  diarrhoeas  are,  so  to  speak,  explosive  in  character.  A 
feeling  of  intestinal  quietude  very  soon  follows  an  attack  developed 
with  inconceivable  rapidity,  and  then,  aside  from  a  slight  weari- 
ness, the  patient  is  relieved  and  well.  In  other  cases  the  attack 
begins   very   suddenly,   but    if    left  untreated    it    may   continue 


536  DISEASES  OP  THE  INTESTINES 

many  hours  or  days.  I  have  recently  seen  a  very  typical  case  of 
this  kind. 

The  etiological  factors  of  the  attacks  vary,  and  depend  chiefly 
upon  the  particular  psychic  idiosyncrasy  of  the  individual.  In  an 
excellent  article  on  Gastric  Keuroses,  Fleiner  ^^  relates  how  students 
before  their  first  duels,  and  physicians  before  applying  forceps  dur- 
ing labour,  previously  visit  the  water  closet.*  These  are  examples  of 
very  acute  emotional  diarrhoea  (diarrhoea  produced  by  fear).  In 
chronic  cases,  occupation  frequently  determines  the  attacks.  For 
example,  I  have  often  observed  nervous  disorders  in  bankers  and 
stock  speculators  under  the  influence  of  sudden  great  financial 
crises.  In  actors,  a  debut,  a  gala  or  a  first  performance  may  in- 
duce peristaltic  hypermotility.  Canstatt^^  reports  the  case  of  a 
physician  who  was  attacked  with  watery  diarrhoea  before  every 
large  operation.     Numerous  other  examples  might  be  given. 

Before  proceeding  to  the  diagnosis  I  shall  describe  several  cases 
which  illustrate  the  above  remarks. 

I. — Mr.  S.,  wine  merchant  of  Berlin,  forty-six  years  of  age;  comes  from 
a  nervous  family,  and,  as  he  himself  says,  has  been  nervous  for  years.  Was 
formerly  addicted  to  excessive  drinking,  especially  of  champagne.  Patient  is 
married  to  a  very  nervous  and  jealous  woman.  He  complains  of  the  following 
attacks  which  occur  from  three  to  five  times  yearly :  After  any  great  excite- 
ment he  is  suddenly  attacked  by  severe  gastric  colic,  together  with  profuse 
diarrhoea.  Even  the  blandest  nourishment  is  passed  in  a  few  minutes.  The 
attacks  last  three  or  four  days,  during  which  time  the  appetite  is  very  poor. 
The  patient  improves  gradually.  In  the  interval  between  the  attacks  the  gastric 
functions  are  normal. 

The  last  attack  occurred  on  June  3,  1898,  in  consequence  of  great  agitation 
at  his  home.  The  patient  suffered  intense  pain,  causing  him  to  toss  about  and 
to  break  out  into  a  cold  perspiration.  The  pain  always  begins  during  the  day, 
but  ceases  at  night.  It  is  independent  of  food  ingestion.  There  are  twenty  to 
thirty  almost  watery  stools  per  day,  accompanied  by  severe  tenesmus. 

Status  Pr mens. — Muscular,  florid-looking  man;  pulmonary  organs  normal. 
Marked  diffuse  sensitiveness  to  pressure  in  the  gastric  region,  disappearing 
when  the  patient's  attention  is  withdrawn.  Posteriorly,  alongside  the  verte- 
bral column  there  are  numerous  scattered  pressure  points.  Patellar  and  pupil 
reflexes  are  somewhat  sluggish.  No  disturbances  of  sensibility,  no  Romberg's 
symptom. 

This  case  gives  the  impression  of  a  visceral  crisis,  and  we  cannot 
exclude  the  possibility  that  the  above  symptoms  represent  begin- 

*  In  his  celebrated  novel  Debacles,  Zola  has  forcibly  described  the  reflex  action 
upon  intestinal  peristalsis  resulting  from  the  enemy's  artillery  fire. 


NERVOUS  DISEASES  OP  THE  INTESTINES  537 

ning  locomotor  ataxia.  At  present,  however,  corroborative  symp- 
toms are  absent,  so  that  we  may  regard  the  case  as  one  of  secretory 
neurosis.     The  etiology  also  speaks  in  favour  of  this  diagnosis. 

II. — Mrs.  L.  T.,  of  Berlin,  aged  thirty-three;  teacher.  For  years  patient 
has  suffered  from  nervous  disturbances  of  the  stomach  and  intestines;  for 
example,  vomiting  and  diarrhoea  occurred  frequently  at  examinations.  Later, 
this  condition  improved,  but  about  three  months  after  an  operation  for  fistula 
in  ano  it  returned.  Since  that  time  diarrhoea  frequently  occurs  after  the 
slightest  excitement ;  thus  the  thought  of  consulting  a  physician  or  of  meeting 
strangers  produces  intestinal  hyperperistalsis.  There  is  also  a  predisposition  to 
diarrhoea  when  the  patient  makes  a  social  call  and  cannot  reach  the  toilet  room 
unobserved.  In  her  own  home,  however,  such  attacks  do  not  occur.  Diet  has 
absolutely  no  effect  upon  the  attacks — e.  g.,  the  stools  may  be  quite  normal 
after  eating  fruit,  vegetables,  rye  bread,  or  cake.  Appetite  always  good.  Pa- 
tient is  anaemic,  has  cold  extremities  (mains  serpentines).  Except  for  mild 
sphincteric  paresis  all  organs  are  normal. 

Treatment. — Arsenic,  which,  according  to  patient,  is  very  successful. 

III. — Mr.  L.,  fifty  years  old,  director  of  a  chemical  factory  in  Boston; 
antecedents  of  both  parents  nervous.  The  sisters  of  the  patient  are  more  or 
less  neurotic,  but  severe  diseases  of  the  nervous  system  have  never  appeared 
in  the  family.  The  patient  himself  is  easily  excitable,  but  is  of  happy  tem- 
perament. 

Has  had  his  present  trouble  for  ten  years.  It  shows  itself  in  occasional 
diarrhoea,  which  occurs  particularly  when  the  patient  is  prevented  from  or 
embarrassed  in  seeking  the  toilet.  This  is  specially  the  case  during  railroad 
trips.  He  must  always  ride  in  a  railroad  coach  containing  a  toilet.  When  the 
patient  is  invited  to  dinner  it  often  happens  that  he  must  leave  because  of 
sudden  intestinal  hypermotility.  When  going  to  the  theatre  he  always  takes 
an  end  seat,  so  as  to  be  able  to  leave  quickly  if  necessary.  Otherwise  the 
stools  are  entirely  regular;  the  appetite  is  fair;  sleep  and  general  condition 
good. 

The  patient  is  a  strong,  well-nourished  man.  Objective  signs  (including 
examination  of  the  faeces)  are  normal. 

IV. — Mrs.  G.,  of  Moscow,  aged  twenty-nine;  merchant's  wife.  The  pres- 
ent affection  dates  back  six  years,  and  began  with  her  puerperium.  It  com- 
menced with  severe  intestinal  colic  and  rumbling  and  fluid  stools  mixed 
with  mucus  and  blood.  Improvement  after  three  or  four  days.  Since  then 
there  has  been  marked  sensitiveness  of  the  intestines,  particularly  when  the 
patient  is  excited.  For  example,  the  colic  and  diarrhoea  begin  when  she  is 
frightened  or  worried;  once  an  attack  occurred  when  her  child  was  sick,  and 
again  when  she  had  toothache  and  migraine.  Rest  has  a  favourable  effect. 
Diet  has  no  appreciable  influence.  In  the  intervals  between  the  paroxysms 
the  patient  has  normal  stool  daily  or  every  second  day.  During  pregnancy  and 
after  labour  the  attacks  are  more  severe  and  frequent. 

On  June  19,  1898,  the  patient  was  admitted  to  my  private  clinic  for  careful 
observation. 

I  pass  over  unimportant  details  and  mention  only  the  intestinal  phenomena. 


538  DISEASES   OF  THE  INTESTINES 

There  is  marked  sensitiveness  along  the  entire  course  of  the  Irrge  intestine, 
particularly  over  the  caecum,  the  descending  colon,  and  the  sigmoid  flexure. 

Examination  of  the  Fmes. — These  are  formed  and  covered  with  thick,  tena- 
cious mucus.  Microscopically  there  is  much  degenerated  epithelium,  in  several 
places  striated  ground  substance,  in  which,  by  the  addition  of  acetic  acid, 
numerous  nuclei  are  seen.  Test  lavage  of  the  intestine  also  shows  small  shredded 
or  gelatinous  masses  of  mucus. 

Treatment. — Astringent  diet  as  in  chronic  diarrhoea.  Improvement.  On 
June  2oth,  after  a  long  visit  of  a  relative  from  Leipzig,  she  had  five  fluid  evacu- 
ations accompanied  by  severe  pain.  Despite  fluid  diet  she  had  continuous 
tenesmus  and  about  twenty  movements  during  the  night  of  June  35th.  The 
stools  were  brown  and  watery;  microscopically  they  showed  nothing  special. 
Tincture  of  opium  and  warm  fomentations  were  ordered.  On  the  next  day  a 
feeling  of  marked  tension  in  the  abdomen  and  of  great  weakness.  The  stools 
soon  became  firm  and  less  frequent  as  the  patient  rapidly  recovered,  and  left 
the  clinic  on  July  5th.  After  a  course  at  Franzensbad  she  was  completely 
cured. 

The  diagnosis  of  nervous  diarrhoea  may  be  simple  or  difficult. 
TThere,  as  in  the  second  and  third  cases,  the  nervous  factor  is  pre- 
dominant, the  affection  occurs  periodically  with  normal  conditions 
during  the  intervals,  the  diet  has  no  influence  upon  the  course  of  the 
disease,  the  clinical  examination  shows  other  symptoms  of  neuras- 
thenia, and  the  stools  exhibit  no  signs  of  catarrhal  enteritis,  the 
diagnosis  can  readily  be  made. 

If,  however,  the  condition  becomes  chronic,  the  diagnosis  is  less 
simple.  Thus,  in  the  fourth  case  there  is  as  much  ground  for  as 
against  the  assumption  of  a  nervous  origin.  The  absence  of  mucus 
in  the  dejections — a  point  on  which  Nothnagel  lays  great  stress — is, 
according  to  my  own  experience  and  that  of  von  Engelhardt  ^^,  by 
no  means  a  positive  differential  fact.  Despite  the  nervous  basis  of 
the  disease,  a  catarrh  may  develop,  or  an  otherwise  mild  clinical 
enteritis  may,  from  mental  excitement,  suddenly  become  worse  and 
present  symptoms  of  a  severe  intestinal  catarrh.  There  will  be 
mucus  in  the  stools,  and  yet  in  both  instances  the  diarrhcBa  is 
neurotic. 

In  his  excellent  treatise  von  Engelhardt  attempts  to  introduce 
other  facts  for  the  differentiation  between  true  enteritis  and  intes- 
tinal neuroses.  He  distino-uishes  between  these  two  conditions  as 
follows : 

Chronic  Intestinal  Catarrh. — There  is  generally  loss  of  weight 
and  anaemia.  When  diarrhoea  takes  place  it  is  usually  during  the 
night  or  in  the  early  morning,  and  comes  on  at  irregular  intervals 
during  the  day.     Diet  has  a  marked  effect  upon  the  character  of 


NERVOUS  DISEASES   OP   THE  INTESTINES  539 

the  stool  and  upon  the  patient's  general  condition.  There  is  sensi- 
tiveness to  pressure  over  the  colon. 

Intestinal  Neuroses. — No  loss  of  weight ;  frequently  robust 
appearance  despite  diarrhoea  for  many  years.  The  diarrhoea  gen- 
erally occurs  at  the  usual  time  of  defecation  or  immediately  after 
eating.  Evacuations  follow  one  another  rapidly,  and  then  cease  for 
a  long  time.  Diet  has  almost  no  effect  upon  the  attacks,  or  they 
may  cease  after  a  mixed  diet.  Sensitiveness  to  pressure  over  the 
aorta  and  the  iliac  arteries. 

The  facts  cited  by  von  Engelhardt  are  doubtless  of  diagnostic 
value,  as  the  clinical  histories  just  given  illustrate.  In  individual 
cases,  however,  his  points  of  differentiation  may  leave  us  in  the  dark. 
For  example,  I  have  repeatedly  seen  morning  diarrhoeas  in  typical 
neurasthenics  whose  intestinal  functions  were  otherwise  normal. 
Again,  the  general  condition  of  a  patient  with  intestinal  neurosis  is 
not,  as  von  Engelhardt  maintains,  always  excellent.  In  the  second 
case  I  have  described  I  find  in  my  journal  "  the  patient  lost  5  kilo- 
grams within  a  short  time."  It  follows,  therefore,  that  in  view 
of  the  innumerable  possible  combinations  of  the  protean  picture  of 
intestinal  neurosis,  all  scientific  considerations  may  occasionally 
mislead.  A  clear  conception  of  the  disease  is  possible  only  from 
systematic  and  most  careful  observation ;  often  we  can  only  estab- 
lish the  diagnosis  from  the  course  of  the  aifection,  or  from  the 
results  of  treatment. 

Treatment 

This  will  vary  with  the  type  of  the  disease.  The  classification 
previously  made  (page  535)  shows  that  in  the  intervals  between 
attacks  the  intestinal  function  is  sometimes  normal.  In  such  cases 
treatment  will  be  directed  toward  the  general  condition,  the  gen- 
eral and  local  neurotic  irritability,  and  the  diarrhoeas  tliemselves 
when  these  become  excessive.  For  the  last-named  condition  opium 
is  undoubtedly  the  most  appropriate  remedy.  Dietetic  treatment 
is  of  secondary  importance.  In  continuous  intestinal  irritability  the 
treatment  should  be  different.  A  diet  similar  to  that  of  chronic  diar- 
rhoea (see  pages  224  and  225)  will  frequently,  though  not  always, 
prevent  an  attack.  In  chronic  neurotic  diarrhoea  the  same  princi- 
ples apply.  In  addition,  hydrotherapeutics,  and  in  some  cases 
electricity  (galvanism),  may  be  beneficial.  For  obvious  reasons  the 
best  results  are  achieved  by  sanitarium  treatment. 

Of  medicinal  remedies,  the  bromid  preparations  (bromid  of  soda. 


540  DISEASES  OP  THE  INTESTINES 

0.5,  one  powder  t.  i.  d.)  deserve  first  consideration.  According  to 
JSTothnagel  (see  also  Case  II),  the  arsenical  preparations  (Fowler's 
solution,  3  to  5  drops  t.  i.  d.,  in  peppermint  water)  may  liave  a 
favourable  effect.  For  anaemic  patients,  iron  springs  (Franzensbad, 
Elster,  Pyrmont,  Cudowa,  Rippoldsau)  may  be  of  benefit.  Carlsbad 
thermal  water  taken  hot  and  in  small  doses  is  sometimes  followed 
by  good  results.* 

(b)  Mucous  Colic 

In  discussing  membranous  enteritis  (page  228)  we  mentioned 
mucous  colic  and  the  different  theories  regarding  its  origin.  There 
can  be  no  doubt  that  periodical  membranous  dejections  are  frequently 
observed  in  neurasthenic  and  hysterical  women.  But — and  this  is 
the  distinguishing  characteristic — they  scarcely  ever  occur  without 
simultaneous  habitual  (generally  spastic)  constipation.  Since  we 
know  that  in  predisposed  individuals  conditions  of  obstinate  con- 
stipation form  the  basis  for  all  kinds  of  nervous  and  hysterical 
symptoms,  we  do  not  consider  mucous  colic  as  a  symptom  of 
hysteria  or  neurasthenia,  but  only  of  constipation.  When  the 
latter  is  well  marked  mucous  colic  occurs,  and  it  ceases  when  the 
constipation  is  no  longer  present.  I  do  not  know  of  a  single 
instance,  either  from  personal  observation  or  from  literature,  in 
which  the  mucoid  dejections  did  not  cease  when  the  bowels  were 
regular.  In  view  of  these  facts,  the  theory  still  maintained  by  sev- 
eral authors  that  mucous  colic  is  a  secretory  neurosis  is  incorrect. 

It  is  therefore  unnecessary  for  us  to  give  a  separate  description  of 
this  affection  ;  that  in  the  section  on  Membranous  Enteritis  sufiäces. 

4.    Complex  Intestinal  Neuroses 

Intestinal  Neurasthenia 

We  have  stated  (page  521)  that  abnormal  disturbances  of  func- 
tion may  frequently  find  their  outlet  along  the  course  of  different 
nerves,  so  that  motor,  sensory,  secretory,  and  probably  also  vaso- 
motor disturbances  of  innervation  may  be  variously  combined.  In 
this  manner  there  result  intestinal  conditions  similar  to  those  pro- 
duced in  the  stomach  by  nervous  dyspepsia. 

Cherchewski  ^^  was  the  first  to  give  a  detailed  description  of 


*  [For  corresponding  springs  and  wells  in  the  United  States,  see  pp.  161,  164, 
and  165.— Tr.] 


NERVOUS  DISEASES  OP  THE  INTESTINES  541 

intestinal   neurasthenia.     He   directed    special   attention   to    tliree 
characteristic  symptoms,  viz. : 

1.  Habitual  constipation,  rarely  alternating  with  diarrhoea. 

2.  Abdominal  distention,  particularly  in  the  region  of  the  false 
ribs. 

3.  Loud,  tasteless,  odourless  eructations  which  only  exceptionally 
are  acid. 

These  symptoms  are  also  found  in  spastic  constipation,  in  nerv- 
ous flatulence,  and  in  membranous  enteritis.  (Instances  of  the 
latter  condition  doubtless  figure  among  the  author's  cases.) 

Under  the  term  "  nervous  digestive  weakness,"  Möbius  ^'*'  some 
years  ago  described  a  widely  different  type.  In  this,  despite  excel- 
lent appetite  and  abundant  nourishment,  the  patients,  without  suf- 
fering any  subjective  digestive  symptoms,  become  more  and  more 
emaciated.  Their  evacuations  are  apparently  normal,  but  really 
are  overabundant,  and  a  large  part  of  their  nourishment  undoubtedly 
passes  away  unabsorbed. 

It  is  well  known  that,  notwithstanding  sufficient  nourishment, 
individuals  may  persistently  emaciate,  but  it  is  questionable  whether 
we  are  not  dealing  with  minute,  as  yet  unknown,  anomalies  of  food 
metabolism.  In  my  opinion,  there  is  at  present  no  reason  for  a 
special  description  of  intestinal  nenrasthenia  as  an  individual  clin- 
ical picture  such  as  is  found  in  the  text-books  of  Rosenheim  and 
Pick.  If  we  possessed  a  more  or  less  complete  clinical  syndrome, 
we  would  be  justified  in  separating  this  from  the  other  forms  of 
intestinal  neurosis.  Since  such  is  not  the  case,  we  must  limit  our- 
selves to  the  statement  that  functional  disturbances  of  the  most 
varied  kinds  may  be  combined  with  one  another,  and  thus  produce 
an  ensemble  whose  individual  traits  are  entirely  dissimilar. 

LITERATURE 

1.  Jürgens.     Verhandl.   des  III.  Congresses  f.  innere  Medicin,  1884,  S.  252  ; 

Berl.  klin.  Wochenschr.,  1893,  S.  357. 

2.  Blaschko.     Virchow's  Archiv,  Bd.  xciv,  S.  136. 
8.   Sasaki.     Ibid.,  Bd.  xcvi,  S.  387. 

4.  Schleimpflug.     Zeitschr.  f.  klin.  Medicin,  1885,  Bd.  ix,  S.  40, 

5.  Emminghaus.     Munch,  med.  "Wochenschr.,  1894,  No.  5  u.  6. 

6.  Nothnagel.     Darmkrankheiten,  S.  482. 

7.  Peyer.     Die  nervösen  Affectionen  des  Darms  bei   der   Neurasthenie   des 

männlichen  Geschlechtes,  Wiener  Klinik,  1893. 

8.  Kussmaul.     Volkmann's  Samml.  klin.  Vorträge,  1878,  No.  53. 

9.  Boas.     Verhandl.  des  XV.  Congresses  f.  innere  Medicin,  1897,  S.  479,  etc. 
10.  Rosenheim.     Pathologie  u.  Therapie  d.  Krankheiten  d.  Darms,  S.  492. 


542  DISBASES  OF  THE  INTESTINES 

11.  Federn.     Ueber  partielle  Darmatonie,  Wiener  Klinik,  1891  ;  Blutdruck  u. 

Darmatonie,    Wien,    1894;    Ueber   Darjmatonie,  Wiener  med.    Presse, 
1895,  No.  25-28. 

12.  M.  Herz.     Wiener  med.  Wochenschr.,  1897,  No.  36  u.  37. 

13.  Fleiner.     Archiv  f,  Verdauungskrankheiten,  1895,  Bd.  i,  S.  243. 

14.  Canstatt.      Prager  Vierteljahrschrift,   1849,  iii,   99.     Cited  from  Henoch, 

Klinik  d.  Unterleibskrankheiten,  iii,  S.  176. 

15.  R.  von  Engelhardt.     Petersburger  med.  Wochenschr.,  1895,  No.  48. 

16.  Cherchewski.     Revue  de  medecine,  1883,  p.  876,  etc.,  and  1033,  etc. 

17.  Möbius.     Centralbl.  f.  Nervenheilkunde,  Bd.  vii,  S.  4. 


LIST   OF   SUBJECTS 


Abdomen,  inspection  of,  in  intestinal  dis- 
eases, 67. 
Abscess,  perityphlitic,  448. 
Absorption,  intestinal,  86. 

from  large  intestine,  37. 

from  small  intestine,  40. 

from  rectum,  40. 
Acetonuria,  134. 
Acholia.     See  Stools. 
Achylia  gastrica,  relation  to   dyspeptic 

diarrhoea,  221. 
Acid,  acetic,  42,  103,  206. 

biliary,  29,  30,  108. 

butyric,  46,  103,  206. 

caproic,  206. 

carbonic,  45-48. 

ethereal  sulphuric,  45,  133. 

fatty,  42,  102,  103,  125. 

formic,  206. 

hydroparakumaric,  45. 

lactic,  46,  206. 

oxy-,  46. 

phenyl-acetic,  45. 

phenyl-propionic,  45.- 

phenyl-sulphuric,  46. 

propionic,  103,  206. 

succinic,  46,  103,  206. 
Adenomata,  333.     See  Polypi. 
Adhesions,    obstructions    produced    by, 
392,  393. 

strangulation  produced  by,  372. 
Albumin,  determination  of,  in  fasces,  100. 

digestion  of,  37,  140. 
Albuminuria,  134. 
Albumoses,  determination   of,  in  fjeces, 

101. 
Ammonia,  47.  48. 
Antipepton,  27. 
Anti-peristalsis,  34. 
Antiseptics,  intestinal,  199. 


Anus,  inspection  of,  77.     See  Inspection, 
Rectal. 

palpation    of,     77.       See    Palpation, 
Rectal. 
Appendicitis,  430. 

actinomycotic,  437 ;  operation  in,  466. 

American  views  of,  466. 

as  a  surgical  disease,  467,  471. 

bacteria  in,  435. 

complications  of,  453 ;  chronic  intes- 
tinal obstruction,  455 ;  emboli 
and  thrombi,  454;  empyema,  454; 
mode  of  origin,  454 ;  pleurisy, 
454;  pylephlebitis,  454  ;  pregnan- 
cy, 455 ;  secondary  abscess,  454, 
470  ;  suppurative  pericarditis,  454; 
thoracic  and  abdominal  fistulae, 
454. 

etiology,  434. 

faecal  concretions  in,  435. 

frequency  of,  435,  437. 

larvata,  453. 

operation,  contraindications  to,  471  ; 
indications  for,  470. 

pathologico-anatomical  considerations, 
434,  467. 

pseudo-perityphlitis,  453. 

septic,  453. 

synonyms  of,  430. 

treatment,  457,  468  ;  conservative,  457, 
468;  surgical,  461,470. 

tuberculous,  437  ;  operation  in,  465. 
Appendicitis,  acute,  430,  433. 

diagnosis  from  biliary  and  renal  colic, 
449 ;  from  cjecal  tumours,  813, 
451 ;  from  disease  of  the  female 
adnesa,  450 ;  from  intestinal  ob- 
struction, 368,  452  ;  from  typhoid 
fever,  458 ;  in  unusual  positions 
of  the  appendix,  449,  451. 
543 


544 


DISEASES   OP   THE  INTESTINES 


Appendicitis,  acute,  diffuse,  446  ;  causes, 
446;  diagnosis,  447;  difEerential 
diagnosis,  453 ;  surgical  treatment 
of,  462,  472. 

perforative,  446;  differential  diagno- 
sis, 452. 

prophylaxis  of,  457. 

puncture,  intestinal  in,  441. 

simple,  catarrhal,  440  ;  differential 
diagnosis,  449  ;  symptoms,  440  ; 
gastric  disturbances,  443 ;  onset, 
440;  pain,  440;  pressure  sensi- 
tiveness, 440  ;  pulse,  444 ;  tem- 
perature, 443  ;  tumour,  441 ;  treat- 
ment, 458 ;  surgical  measures  in, 
462. 

suppurative,  circumscribed,  462 ;  sur- 
gical treatment  of,  462,  472. 

treatment,  457  ;  after-treatment,  460  ; 
conservative,  458, 468  ;  bodily  rest, 
458  ;  diet,  154,  460  ;  ice.  459,  469  ; 
laxatives,  189,  459,  469  ;  opiates, 
154,  194,  458,  469  ;  prophylaxis, 
457 ;  surgical,  461 ;  indications  for 
operations,  464,  470,  471. 

varieties  of,  439. 
Appendicitis,  chronic,  430,  483. 

diagnosis,  448. 

diet  in,  154. 

etiology,  447. 

massage  in,  171. 

obliterans,  448. 

recurring,  447. 

relapsing,  447. 

treatment,  464  ;  internal,  465  ;  opera- 
tive, 465. 

varieties  of,  447,  453. 
Appendicular  colic,  445,  467. 
Appendix,  vermiform,  13. 

palpability  of,  71. 

surgical  anatomy  of,  433. 
Applications,  moist,  175. 

indications  for,  175. 
Atony,  intestinal,  527. 

etiology,  527. 

symptoms,  529. 

treatment,  170,  198,  529. 

varieties  of,  528. 
Auerbach's  plexus,  5. 
Auscultation,  abdominal,  84. 

diagnostic  value  of,  84. 
Axial  torsion.     See  Volvulus. 


Bacteria  in  fa3ces,  119. 

bacillus  putrificus  coli,  121. 

bacillus  subtilis,  121. 

bacterium  coli,  120. 

bacterium  laetis  ferogenes,  121. 

cholera  bacillus,  122. 

Clostridium  butyricum,  121. 

cocci,  122. 

decomposition  by,  45. 

tubercle  bacillus,  122,  267. 

typhoid  bacillus,  122. 
Ballottement,  319. 
Bands,  obstructions  produced  by,  372. 

omental    strangulation    produced  by, 
372. 
Baths,  168. 

classification  of,  168,  175. 

in  conjunction  with  mineral  waters, 
168. 

therapeiatic  indications  for,  168,  515. 
Bauhin's  valve,  13. 
Belladonna,  in   intestinal  diseases,   187, 

195,  415. 
Bile,  29. 

characteristics  and  composition,  29. 

functions  of,  29. 

in  stomach  contents,  130. 

relation  to  digestion.  30. 
Biliary  acids,  29,  30,  108  ;  determination 
of,  in  faeces,  108. 

gravel  in  fasces,  111. 

pigments,  30,  93,  107;  demonstration 
of,  in  fa?ces,  107,  108,  111. 
Bilirubin,  Biliverdin.    See  Biliary  Pig- 
ments. 
Blood,  condition  of,  in  cancer,  301. 
Blood  in  fa?ces.  64,  95,  105,  269,  311,  319, 
496,  500,  512. 

appearance,  microscopical,  106,  117. 

demonstration,  chemical,  106;  micro- 
chemical,  106  ;  spectroscopic, 
106. 

determination  of,  105. 

importance  of,  in  the  history,  64. 

sources  of,  107. 
Bougieing,  rectal,  81. 

diagnostic  significance  of,  81,  82, 
501. 

precautions  to  be  observed  in,  82. 

therapeutic  employment,  83,  503. 
Bougies,  rectal,  A^arieties  of,  81. 
Brunner's  glands,  9,  25. 


LIST   OP   SUBJECTS 


545 


Cfecum,  12  ;  tuberculosis  of.    See  Tuber- 
culosis, Ileo-caecal. 
tumours  of,  271,  312. 
Carbohydrates,  determination  of,  in  faeces, 
102. 
digestion  of,  37,  102,  141 ;  in  the  ab- 
sence of  pancreatic  juice,  42. 
Carcinoma,  intestinal,  296. 
ascites  in,  301. 
body  weight,  300. 
complications,  322. 
condition  of  blood  in,  301. 
cylindrical  epithelial,  298. 
diet,  151,  323. 
etiology,  298. 
frequency  of,  296. 

general  symptoms  and  diagnosis,  300. 
glandular  enlargements,  302. 
heredity  in,  300. 
medullary,  298. 
metastasis,  299. 
oedema  of  ankles,  301. 
pathological  anatomy,  298. 
scirrhous,  298. 

treatment,  322 ;  palliative,  323 ;  surgi- 
cal, 325. 
urine  in,  301. 
varieties  of,  298. 
Carlsbad  Water,  in  duodenal  ulcer,  293^ 
Carminatives,  197. 

Catarrh,  acute  intestinal,  205.     See  En- 
teritis, Acute, 
chronic,  212.     See  Enteritis,  Chronic, 
duodenal,  210. 

of  large  intestine,  222  ;  diagnosis  of, 
222  ;    diet  in,  145  ;  mucus  in,  222. 
of  small  intestine,  218 ;  diagnosis  of, 

218;  diet  in,  144;  stools  of,  219. 
mixed  forms  of,  223. 
Cathartics  in  intestinal  diseases,  186. 
action  of,  186. 
administration,  endermic,  254  ;  rectal, 

187;  subcutaneous,  187,  250. 
contraindications  to  the  use  of,  189. 
in  appendicitis,  189,  459,  469. 
in  children,  190. 
indications  for  the  use  of,  188. 
in  hemorrhoids,  514. 
in  membranous  enteritis,  190. 
in  obstruction  and  stenosis,  413,  418, 
in  typhlitis,  189,  456. 
Centralkoth,  76. 


Chlorophyl  in  the  faeces,  93. 
Cholesterin,  30. 

determination  of,  in  faeces.  111,  123. 
Clefts,  strangulation  produced  by,  372. 
Colic,  appendicular,  445,  467. 

flatulent,  244 ;  diagnosis  from  intesti- 
nal obstruction,  367;   opiates  in, 
196;  treatment,  254. 
mucous,  540. 
vermicular,  445,  467. 
Colitis,   primary,  475.     See   Pericolitis, 

Exudative. 
Colon,  ascending,  13. 
descending,  14. 
displacements  of,  86,  255,  257. 
transverse,  14. 
Coloptosis,  86. 
Colouring  matter,  biliary,  30. 

of  fiBces,  30,  107. 
Compression  of    bowel,   producing  ob- 
struction, 394. 
Constipation,  60, 240. 
acute,  60 ;  cathartics  in,  188 ;    causes 

of,  60. 
alternating  with  diarrhcea,  61,  228. 
chronic,  240;  alimentary,  240;  atonic, 
243;     cathartics     in,      188,     251; 
causes  of,  61  ;  diagnosis,  245  ;  diet 
in,  146,  227,  247;    electricity   in, 
250;  fragmentary,  243;   in  carci- 
noma, 308 ;   in  chronic   enteritis, 
223,  227;  in  obstruction  of  large 
intestine,  361  ;  in  stenosis  of  large 
intestine,  354  ;     massage  in,  249 ; 
mineral  waters  in,  159,  161,  162, 
166 ;  opium  in,  187 ;  predisposing 
to  intestinal  cancer,  61 ;   prophy- 
laxis of,  247;  rectal  examination 
in,  245;   spastic,  243;  symptoms, 
242  ;  treatment  of,  168.  227,  246. 
habitual,  240.    See  Chronic, 
mineral  waters  in,  159. 
significance  of,  as  a  symptom,  60. 
Coproliths,  112.     See  Stones. 
Crystalline  bodies  in  faeces,  123. 
ammonium  -  magnesium    phosphates, 

126. 
bismuth,  126. 
calcium  oxalate,  126. 
calcium  phosphate,  125. 
calcium  sulphate,  126. 
Charcot-Leyden  crystals,  123,  236. 


546 


DISEASES  OF  THE  INTESTINES 


Crystalline  bodies  in  f;eces,  Cholesterin, 
123. 
fatty  acids,  125. 
fatty  soaps,  125. 
liaematoidin,  123. 

Decubital  intestinal  ulcer,  262. 
Diaceturia,  134. 
Diarrhoea,  62. 

acute,  62,  192,  207;  diet  in,  143,  211; 
remedies  in,  192. 

chronic,  62  ;  causes  of,  62  ;  diet  in,  149, 
224;  in  chronic  enteritis,  219,  223, 
224;  medicinal  remedies  in,  192, 
226;  mineral  waters  in,163,164,166. 

dyspeptic,  62,  220. 

false,  500. 

nervous,  534;  diagnosis,  538  ;  from 
chronic  enteritis,  538  ;  diet  in,  155, 
539 ;  etiology,  535 ;  symptoms, 
535 ;  treatment,  539 ;  varieties,  535. 

significance  of,  as  a  symptom,  62. 

subacute,  192. 
Diet  in  intestinal  diseases,  139. 

fundamental  principles  of,  139, 

general  rules  for,  141. 

in  acute  enteritis,  143,  211. 

in  appendicitis  and  typhlitis,  153,  456, 
460. 

in  cancer  of  large  intestine,  325. 

in  cancer  of  small  intestine,  323. 

in  chronic  constipation,  146,  227,  247. 

in  chronic  diarrhoea,  149,  224. 

in  chronic  enteritis,  144. 

in  diseases  of  mucous  membrane,  142. 

in  duodenal  ulcer,  143,  293. 

in  functional  disturbances,  146. 

in  hemorrhoids,  514. 

in  membranous  enteritis,  237. 

in  neuroses,  155. 

in  rectal  diseases,  156. 

in  stenosis  and  obstruction,  150,  153, 
412,  415. 

in  ulcers,  293. 
Digestion,  intestinal,  43. 

of  albuminoid  bodies,  37. 

of  carbohydrates,  37. 

of  fats,  38. 

of  foods  in  general,  140. 
Disinfection,  intestinal,  199. 
Displacements,  intestinal,  20,  255. 

complications,  256. 


Displacements,  intestinal,  diagnosis,  258. 

etiology,  255. 

symptoms,  255. 

treatment,  259. 
Disturbances,  gastric,  in  intestinal  dis- 
eases, 65. 

in  acute  appendicitis,  443. 

in  acute  enteritis,  208. 

in  cancer,  302,  304. 

in  duodenal  ulcer,  285. 

in  stenosis  and  obstruction,  344,  348, 
355,   381,   388.     See  also  Vomit- 
ing. 
Diverticulum,    strangulation    produced 

by,  373. 
Douche,  rectal,  182. 
Duodenum,  1. 

anatomy  of,  1. 

carcinoma  of,  302 ;  bilious  vomiting, 
303  ;  circumpapillary,  304 ;  diag- 
nosis, 302,  304;  diagnosis  from 
pancreatic  cancer,  306 ;  from  py- 
loric cancer,  302 ;  from  pyloric 
stenosis,  346,  353;  emaciation  in, 
306 ;  gastric  disturbances,  302, 303 ; 
icterus,  305 ;  inf  rapapillary,  302  ; 
pain  in,  303 ;  splashing  sounds, 
303;  suprapapillary,  302;  symp- 
toms, 302,  303,  305 ;  tumour,  306, 
308  ;  vomiting  in,  303  ;  treatment, 
see  Carcinoma,  Intestinal. 

catarrh  of,  210. 

stenosis  of,  346 ;  diagnosis,  346,  349 ; 
etiology,  351,  352 ;  gastric  con- 
tents in,  349  ;  gastric  disturbances, 
348 ;  indicanuria,  349 ;  inf  rapap- 
illary, 348;  meteorism,  348;  stools 
in,  349 ;  suprapapillary,  346 ; 
symptoms,  346,  348;  treatment, 
see  Stenosis,  Intestinal. 

ulcer  of,  280.     See  Ulcer,  Duodenal. 
Dysentery,  chronic,  diagnosis  from  can- 
cer of  large  intestine,  315. 

Electric  trans-illumination  of  intestines, 

88. 
Electricity,  172. 
action  of,  173. 
results  from,  174. 
technic  of,  173. 

therapeutic  indications  for,  174,  250, 
418,  425. 


LIST   OP  SUBJECTS 


547 


Emaciation,  in  chronic  constipation,  245. 
in  intestinal  cancer,  300. 
in  rectal  cancer,  319. 
Enemata,  rectal,  177. 
antiseptic,  193,  278,  485. 
astringent,  193,  278,  485. 
high,  180. 
indications  for,  177,  180,  413,  416,  456, 

515,  531. 
mineral  waters  in,  1C5. 
oil,  178. 

technic  of,  177,  179. 
Enteralgia,  532. 
diagnosis,  533. 
differential  diagnosis,  534. 
etiology,  532. 
opiates  in,  196. 
symptoms,  533. 
treatment,  196,  534. 
Enteritis,  205. 
acute,  205;  alimentary,  206 ;  complica- 
tions of,  208;  diagnosis,  207;  diet, 
143,  211 ;  etiology,  205 ;  faeces  in, 
207;  infectious,  62, 105;  medicinal, 
206;  refrigeration, 207;  symptoms, 
209  ;  toxic,  205 ;  treatment,  210. 
amoebic,  odour  of  fiBces  in,  94. 
chronic,  212;  cathartics  in,  190;  course, 
217;  diagnosis,  217;  diet,  144, 145; 
etiology,  212;  feeces  in,  216 ;  forms 
of.  214;    mineral  waters    in,  164, 
166 ;  pathological  anatomy  of,  213 ; 
symptoms,  214 ;  treatment,  223. 
membranous,  228;   artificial,  230;  ca- 
thartics    in,  190 ;    complications, 
230, 236 ;  course  of,  236 ;  diagnosis. 
236;   enemata    in,   237;   etiology, 
229;    stools    in,   234;    symptoms, 
230 ;  treatment,  236. 
Enteroliths,  112.     See  Stones. 
Enteroptosis,  255. 
Enterospasm,  521. 
diagnosis,  522. 
symptoms,  522. 
treatment,  523. 
Enterostomy  in  malignant  growths,  326, 
333. 
in  obstruction,  426. 
Enterorrhagia.     See  Hemorrhage,  Intes- 
tinal. 
Entozoa,  obstruction  by,  400. 
Epithelium,  in  faeces,  117,  235. 


Evacuations,  intestinal.     See  Faeces  and 

Stools. 
Examination,  rectal,  77. 

digital,  79,  319,  357. 

instrumental,  79. 

manual,  79. 
Excretion,  intestinal,  41. 

auxiliary  to  renal  excretion,  42. 

during  fasting,  41. 

Faecal  tumours.     See  Tumours,  Faecal. 
Faeces,  42,  63,  90.     See  also  Stools. 

admixtures,  pathological,  in,  64. 

albuminoid  bodies  in,  100. 

bacteria  in,  42. 

biliary  matter  in,  107,  219. 

bilirubin  in,  93. 

blood  in,  64,  95,  105,  117,  269. 

calcium  salts  in,  125,  126. 

carbohydrates  in,  102. 

chlorophyl  in,  93. 

Cholesterin  in.  111. 

colour  of,  42,  63,  93. 

colouring  matter  of,  30. 

consistency  of,  63,  93. 

crystalline  bodies  in,  123.  See  Crys- 
talline Bodies. 

effect  of  diet  upon,  42,  93. 

epithelium  in,  117,  219. 

examination  of,  90 ;  arrangements  for, 
91;  chemical,  99;  diagnostic  value 
of,  90;  macroscopical,  91;  micro- 
scopical, 113. 

fats  in,  102,  219. 

ferments  in,  110. 

food  remnants  in,  42,  65,  97,  113. 

form  of,  91. 

frog-spawn  bodies  in,  96. 

gallstones  in.  111. 

importance  of  careful  examination  of, 
63. 

indol  in,  42,  94,  110. 

inorganic  substances  in,  42,  113,  114. 

intestinal  elements  in,  117,  270. 

leukourobilin  in,  105. 

micro-organisms  in,  42,  118. 

mucin  in,  117. 

mucus  in.  64,  92,  207. 

muscle  fibres  in,  97,  113,  219. 

nature  and  composition  of,  42. 

odour  of,  65,  94. 

odourless,  94. 


•548 


DISEASES    OF  THE  INTESTINES 


Faeces,  pancreatic  stones  in,  111. 

parasites  in,  65,  99. 

phenol  in,  109. 

pus  in,  64,  95,  117,  269. 

quantity,  variations  in,  42,  63,  93. 

I'eaetion  of,  99 ;  determination  of,  99 ; 
diagnostic  significance  of,  100. 

significance  of,  in  the  history,  63. 

skatol  in,  42,  94,  110. 

soaps,  fatty,  in,  103. 

starch  granules  in,  115,  219. 

tumour  fragments  in,  64,  99,  311. 

urobilin,  107. 

yellow  mucous  granules  in,  96,  218. 
Fats,  determination  of,  in  faeces,  102. 

intestinal  digestion  of,  38,  104. 
Ferments,  determination   of,   in  faeces, 

110. 
Finger  cots,  78. 
Fissures,  anal,  491. 

diagnosis,  492. 

etiology,  491. 

location,  491. 

symptoms,  492. 

treatment,  492. 
Fistula,  rectal,  488. 

diagnosis,  489. 

etiology,  488. 

symptoms,  489. 

treatment,  490. 

varieties  of,  488. 
Flatulence,  nervous,  531. 

diet  in,  156. 

etiology,  531. 

symptoms,  532. 

treatment,  196,  532. 
Flexure,  sigmoid,  14. 

displacements  of,  23,  258. 

volvulus  of,  376. 
Fold,  transverse  rectal,  18. 
Folds,  Kerckring's,  8. 
Food  remnants  in  faeces,  42,  65,  97,  113. 

significance  of,  97. 
Food  stuffs,  intestinal  digestion  of,  140. 

See  also  Digestion,  Intestinal. 
Foreign  bodies  producing  obstructions, 
396,  401. 

Gallstones,  obstruction  by,  396. 
Gases,  intestinal,  46. 

during  disease,  48. 

during  health,  47. 


Gases,  intestinal,  influence  of  mesenteric 
circulation,  48,  363. 
influence  of  peristalsis,  48. 
sources  of,  46 ;  from  carbohydrates,  47 ; 
fats,  49  ;  proteids,  48. 
Gastric  disturbances.     See  Disturbances, 
Gastric, 
lavage.     See  Lavage,  Gastric. 
Gastro-enteritis,  diet  in,  143. 

opium  in,  192. 
Granules,  yellow  mucus,  in  faeces,  96. 
Growths,  intestinal.     See  Tumours. 
Gurgling,  ileo-caecal,  84. 

Haematemesis.  See  Hemorrhage,  Gastric. 
Hemorrhage,  intestinal,  143,  157. 
diet  in,  142. 
gastric,  in  cancer  of  large  intestine, 

308  ;  in  duodenal  ulcer,  285. 
in  cancer  of  large  intestine,  310. 
in  duodenal  ulcer,  285. 
in  hemorrhoids,  512,  516. 
in  ileo-C£ecal  tuberculosis,  272. 
in  obstruction,  365,  388. 
in  ulcerations,  265. 
Hemorrhoids,  508. 
diagnosis,  513. 
etiology,  509, 
sequelae,  511. 
strangulation  of,  512. 
symptoms,  512. 

treatment,  internal,  514;  baths,  515; 
diet,  514 ;  enemata,  515 ;  laxatives, 
514;  mineral  waters,  515 ;  of  hem- 
orrhage, 516 ;  of  inflammatory 
conditions,  517 ;  of  strangulation, 
517;  toilet  of  the  anus,  516. 
treatment,  surgical,  518  :  "  bloodless," 
518;  "bloody," 519  ;  cauterization, 
519 ;  ligature,  519 ;  local  injec- 
tions, 519 ;  methodical  dilatation 
of  the  sphincter,  518. 
Hernia  diaphragmatica,  374. 

obstruction  from,  370. 
History,  the,  55. 
importance  of,  in  intestinal  affections, 

55. 
scheme  for  obtaining,  56. 
Hydrobilirubin,  30. 
Hydrogen,  45-48. 

sulphuretted,  45,  47. 
Hydrotherapeutic  measures,  158, 175, 250. 


LIST   OF  SUBJECTS 


549 


Icterus,  in  duodenal  ulcer,  286,  292. 

in  intestinal  cancer,  305. 
Ileum,  3. 

cancer  of,  306. 

stenosis  of,  352. 
Ileus,  358.     See  Obstruction,  Intestinal. 
Ileus,  verminosus,  400.     See  Obstruction 

by  Entozoa. 
Iliac  plilegmon,  473. 
Indicanuria,  132,  365,  383. 
Indigo  red,  133,  366. 
Indol,  43 ;  in  the  tseces,  45,  94. 

determination  of,  110. 
Inflation,  intestinal,  84. 

diagnostic  importance,  85, 86,  310,  367, 
383. 

methods  of,  84. 

technic,  85. 

therapeutic  employment,  182,  418, 
Infrapapillary   carcinoma  and   stenosis. 

See  Duodenum. 
Injection  of  water,  86.     See  Water,  In- 
jection of. 
Injections,  rectal,  177.     See  Enemata. 
Inspection  in  intestinal  diseases,  67. 

abdominal,  67. 

rectal,  77;  importance  of,  77;  objective 
results  from,  81 ;  technic  of,  79. 
Intestines,  absorptive  functions  of,  36. 

adenoma  of.     See  Adenoma. 

anatomy  of,  1. 

atrophy  of.     See  Atrophy. 

carcinoma  of.     See  Carcinoma. 

catarrh  of.     See  Catarrh  and  Enteritis. 

contraction  of,  regurgitive,  66 ;  tetanic, 
68. 

disinfection  of,  199. 

displacements  of.    See  Displacements. 

electric  transillumination  of,  88. 

excretory  function,  41. 

gases  of.     See  Gases. 

hemorrhage  of.     See  Hemorrhage. 

histology  of,  3. 

inflation  of.     See  Inflation. 

insufficiency  of,  527. 

intussusception.     See  Intussusception. 

invagination.     See  Intussusception. 

irrigation  of.     See  Irrigation,  Rectal. 

large,  10.     See  Intestine,  Large. 

lavage  of.     See  Lavage. 

lymphosarcoma  of.     See  Sarcoma. 

massage  of.     See  Massage. 
36 


Intestines,  movements  of.     See  Peristal- 
sis. 

myoma  of.     See  Myoma. 

neoplasms.     See  Tumours. 

neuroses  of.     See  Neuroses. 

obstruction  of.     See  Obstruction. 

paresis  and  paralysis  of.     See  Paresis. 

peristalsis  of.     See  Peristalsis. 

physiology  of,  24. 

polypi.     See  Polypi. 

puncture  of,  in  appendicitis,  441  ;  in 
obstruction,  441. 

resection  of,  in  malignant  disease,  326, 
333. 

sarcoma  of.     See  Sarcoma. 

secreting  function,  24. 

small,  1.     See  Intestine,  Small. 

stenosis  of.     See  Stenosis. 

strangulation  of.     See  Strangulation. 

syphilis  of,  266. 

tuberculosis  of.     See  Tuberculosis. 

tumours  of.     See  Tumours. 

ulcers  of.  See  Ulcer,  Duodenal,  and 
Ulcers, 

urine  in  diseases  of.     See  Urine. 
Intestine,  large,  absorption  from,  40. 

anatomy  of,  10. 

atony  of.     See  Atony. 

blood  supply,  15. 

carcinoma  of,  307 ;  appetite  in,  309 ; 
atypical  forms,  312 ;  constipation 
in,  308;  diet  in,  151,  324;  differ- 
ential diagnosis  between  caecal 
tumours  and  appendicitis,  313 ;  be- 
tween malignant  and  benign  intes- 
tinal growths,  313 ;  from  chronic 
intussusception,  314;  from  dysen- 
tery, 315 ;  from  floating  kidney, 
314  ;  ileo-C£ecal  tuberculosis,  277 ; 
from  intestinal  neuroses,  318 ;  from 
tumours  of  other  organs,  314 ;  evac- 
uations, 310 ;  hajraatemesis,  308 ;  in- 
testinal rigidity,  310;  pain,  307; 
palliative  treatment,  323  ;  stomach 
contents,  311 ;  surgical  treatment, 
325;  symptoms,  307,  312;  tenes- 
mus, 308  ;  tumours,  309 ;  typical 
forms,  307  ;  vomiting,  308. 

catarrh  of,  222.  See  Catarrh  and  En- 
teritis. 

displacements  of,  30,  255. 

electric  transillumination  of,  88. 


550 


DISEASES  OF  THE  INTESTINES 


Intestine,  histology  of,  15. 

lymphatics  of,  15. 

nerves  of,  15. 

obstruction  of,  359,  408. 

physiology  of,  24. 

sarcoma  of.     See  Sarcoma,  Intestinal. 

stenosis  of,  354. 

ulcers  of,  273 ;  diagnosis,  273 ;  treat- 
ment, 278.    See  also  Ulcei's,  Intes- 
tinal. 
Intestine,  small,  absorption  from,  36. 

anatomy  of,  1. 

blood  supply,  4. 

carcinoma  of,  302;  diet  in,  151,  323; 
treatment  of,  322,  325.  See  also 
Duodenum,  Carcinoma  of. 

catarrh  of,  218.  See  Catarrh  and  En- 
teritis. 

digestive  functions  of,  43. 

displacements  of,  20. 

histology  of,  5. 

lymphatics  of,  5. 

nerves  of,  5. 

obstruction  of,  359,  406. 

physiology  of,  24. 

sarcoma  of,  329.  See  Sarcoma,  Intes- 
tinal. 

stenosis  of,  346.  See  Stenosis  of  Small 
Intestine. 

ulcers  of,  273  ;  diagnosis  of,  273  ;  treat- 
ment, 277.     See  also  Ulcer,  Duo- 
denal, and  Ulcers,  Intestinal. 
Intussusception,  383. 

diagnosis,  390 ;  differential  diagnosis, 
314,  408,  506. 

etiology,  384,  386. 

frequency  of,  385,  386. 

symptoms,  387 ;  evacuations,  388;  me- 
teorism,  388 ;  pain,  387 ;  tenesmus, 
388  ;  tumour,  389  ;  vomiting,  388. 

terms  employed  in,  383. 

treatment,  internal,  415 ;  surgical, 
423. 

varieties  of,  384. 
Invagination,  383.     See  Intussusception. 
Invertin,  46. 
Irrigations,  rectal,  180. 

indications  for,  180,  456,  485,  503. 

Jejunum,  3. 
cancer  of,  306. 
stenosis  of,  352. 


Juice,  intestinal,  25. 

gastric,  in  duodenal  ulcer,  280,  286. 

pancreatic,  26 ;  influence  upon  intesti- 
nal absorption  of  albuminoids,  37  ; 
of  carbohydrates,  38  ;  of  fats,  39  ; 
in  stomach  contents,  130. 

Kerckring,  folds  of,  8. 

Kinking,  intestinal  obstruction  due  to, 

392. 
Klebesymptom,  Gersuny's,  77. 

Lavage,  intestinal,  177. 

gastric,  indications  for,  183 ;  in  car- 
cinoma, 325  ;  in  obstruction,  416  ; 
technic  of,  184. 

in  intestinal  putrefaction,  200. 

test,  87.     See  Test  lavage. 
Laxatives,  186.     See  also  Cathartics. 

chemical,  147. 

physical,  147,  190. 

thermic,  148. 
Leucocytosis,  in   differential  diagnosis, 

453. 
Leukourobilin,  105. 
Lieberkiihn's  glands,  8,  16,  25. 
Lientery,  222. 
Lipoma,  intestinal,  335. 
Lymphosarcoma,  329.    See  Sarcoma. 

Marsh  gas,  47,  48. 

Massage  in  intestinal  diseases,  171. 

dangers  of,  171,  172. 

indications  for,  171,  249,  460,  517. 

technic  of,  170. 
Meckel's  diverticulum,  strangulation  by, 

373. 
Meissner's  plexus,  5. 

Mesenteric    contraction    producing   ob- 
struction, 394. 
Meteorism,  59. 

diagnostic  significance  of,  59. 

in  carcinoma  of  large  intestine,  310. 

in  intestinal  stenosis,  344,  348,  352,  355. 

in  intestinal  ulcers,  270. 

in  obstruction,  363,  381,' 388. 
Methyl  mercaptan,  45. 
Micro-organisms  in  faeces,  118. 
Mineral  waters  and  springs,  158.    See 

Waters,  Mineral. 
Movements,  peristaltic,  31.     See  Peri- 
stalsis. 


LIST  OF  SUBJECTS 


551 


Mucin, determination  of,  in  faeces,  100, 117. 
Mucus  in  ffeces,  64,  95,  319. 

diagnostic  significance  of,  95. 

in  acute  enteritis,  207. 

in  catarrh  of  the  large  bowel,  222. 

in  catarrh  of  the  small  bowel,  219. 

in  chronic  enteritis,  216. 

in  membranous  enteritis,  235, 

macroscopic  appearance,  96. 

microscopical  appearance,  117. 
Muscle  fibres  in  fteces,  97,  113,  219. 
Myoma,  intestinal,  335. 

diagnosis,  336. 

location,  336. 

origin,  336. 

rectal,  337. 

symptoms,  336. 

treatment,  338. 

varieties  of,  336. 

Neoplasms,  296.     See  Tumours. 
Nervous  digestive  weakness,  541. 
Neuralgia  plexus  mesenterici,  532.     See 

Enteralgia. 
Neurasthenia,  intestinal,  540. 
Neuroses,  intestinal,  521. 
complex,  540. 
diet  in,  155. 

motor,  521.     See  Atony  and  Paralysis 
of    the     Intestine,    Enterospasm, 
Flatulence,  Proctospasm,  and  Tor- 
mina Intestinorum  Nervosa, 
secretory,  534,    See  Diarrhoea,  Nerv- 
ous, and  Colic,  Mucous, 
sensory,  532.     See  Enteralgia. 
Nitrogen,  48. 

Obstruction  by  bands,   clefts,  fenestra, 
and  internal  hernise,  370. 

diagnosis,  376. 

symptoms,  375. 
Obstruction,  intestinal,  358. 

by  adhesions,  bendings,  compressions, 
kinking,  and  mesenteric  contrac- 
tions, 392 ;  symptoms  and  diagno- 
sis, 395. 

by  enteroliths,  399. 

by  entozoa,  400. 

by  faecal  tumours,  402. 

by  foreign  bodies,  396. 

by  gallstones,  396. 

by  introduction  of  foreign  bodies,  401. 


Obstruction,  intestinal,  cathartics  in,  189. 

diagnosis,  367 ;  from  appendicitis,  368 ; 
biliary  and  renal  colic,  367;  chol- 
era nostras  and  Asiatica,  368  ;  flat- 
ulent colic,  367;  peritonitis,  368; 
poisoning,  308. 

differential  diagnosis  between  the  dif- 
ferent forms  of,  405. 

dynamic,  403,  410. 

large  intestinal,  359,  408. 

paralytic,  403. 

small  intestinal,  359,  406. 

spastic,  404. 

symptoms,  359;  constipation,  361; 
general  condition,  366 ;  hemor- 
rhage, 365  ;  meteorism;  363,  388 ; 
pain,  360 ;  peristalsis,  365  ;  pres- 
sure sensitiveness,  360 ;  tympani- 
tis, SO."? ;  urine,  365  ;  vomiting,  361. 

through  volvulus.     See  Volvulus. 

treatment,  411,  415;  diet,  153,  415; 
electricity,  418,  425  ;  enemata,  416, 
425  ;  gastric  lavage,  416  ;  intestinal 
inflation,  418  ;  intestinal  puncture, 
418 ;  medicinal,  418,  425  ;  opiates, 
195,  419  ;  surgical,  420. 

von  Wahl's  symptom  in,  363. 

without   physical   intestinal    changes, 
403  :  diagnosis,  405 ;  etiology,  403  ; 
symptoms,  405  ;  treatment,  425. 
CEdema  of  the  ankles  in  carcinoma,  301. 

in  sarcoma,  332. 
Opiates,  action  of,  upon  tlie  intestines, 
194. 

in  appendicitis,  154,  194,  458,  469. 

in  constipation,  187. 

in  diarrhoea,  192,  196. 

in  proctitis,  485. 

in  stenosis  and  obstruction,  195,  413, 
419. 

Pain  and  pressure  sensitiveness,  72, 
as  a  symptom,  significance  of,  56. 
in  appendicitis,  56,  72. 
in  central  nervous  diseases,  58. 
in  duodenal  ulcer,  57,  72. 
in  intestinal  carcinoma,  303,  308,  307. 
in  intestinal  ulcers,  268. 
in  peritonitis,  57,  72. 
in  rectal  carcinoma,  319. 
in  stenosis  and  obstruction,  57, 344, 361, 
388. 


552 


DISEASES   OP   THE   INTESTIIN'ES 


Pain,  nervous,  58. 

periodic,  58. 

qualities  and  characteristics  of,  56. 

rectal,  59. 
Painfulness,  pseudo-,  73. 
Palpation,  abdominal,  69. 

importance  of,  69. 

in  a  warm  bath,  70. 

of  individual  intestinal  segments,  71. 

technic  of,  69,  70. 
Palpation,  rectal,  77. 

importance  of,  77. 

technic  of,  78. 
Pancreatic  juice.     See  Juice,  Pancreatic. 

diastase,  28. 

stones,  112. 
Papillary  carcinoma  and  stenosis.     See 

Duodenum. 
Paraeresol,  45. 
Paralysie  reflexe,  403. 
Paresis  and  Paralysis  of  Intestine,  527. 
See  Atony,  intestinal. 

rectal,  530  ;  etiology,  530 ;  symptoms, 
530;  treatment,  531. 
Peptones,  determination  of,  in  fsBces,  101. 

intestinal  absorption  of,  37. 

occurrence  in  fasces,  102, 
Percussion,  abdominal,  83. 

objective  results  from,  83. 

palpatory,  83. 

precautions  to  be  observed  in,  83. 

value  of,  83. 
Pericolitis,  exudative,  475. 

diagnosis,  478. 

pathology,  476. 

symptoms,  477. 

treatment,  478. 
Periproctitis,  486. 

acute,  487;  symptoms,  487;  treatment, 
488. 

chronic,   487 ;   diagnosis,   487 ;   symp- 
toms, 487  ;  treatment,  488. 

etiology,  486. 

sequelse  of,  486. 
Peristalsis,  intestinal,  31. 

agents  which  influence,  35,  146. 

felt  by  the  patient,  66. 

in  disease,  36. 

nervous  mechanism  of,  34. 

rapidity  of,  33. 

varieties  of,  32. 

visible,  68,  345,  365,  381. 


Peristaltic  restlessness.    See  Tormina  In- 

testinorum  Xervosa. 
Peritonitis,   localized,   massage  in,   171, 
172.' 

perforative,  in  duodenal  ulcer,  291. 
Perityphlitis,  430.     See  Appendicitis. 
Peyer's  patches,  10. 
Phenol,     determination    of,    in     f.Tces, 

109. 
Polypi,  intestinal,  333. 

diagnosis,  335. 

location  of,  333. 

metamorphosis  of,  334. 

multiple,  334. 

rectal,  335. 

symptoms,  335. 

treatment,  338. 

varieties  of,  333. 
Polyposis,  general  intestinal,  338. 
Postappendicitis,  447. 
Pressure  sensitiveness,  72,  222.     See  also 

Pain. 
Proctitis,  482. 

acute,  483;  diagnosis,  483  ;  symptoms, 
483 ;  treatment,  484. 

chronic,   483;   diagnosis,   484;   symp- 
toms, 483 ;  treatment,  485. 

etiology,  482. 

varieties  of,  482. 
Proctospasm,  521. 

diagnosis,  522. 

etiology,  522. 

symptoms,  522.       ^ 

treatment,  523. 
Prolapse,  rectal,  505. 

diagnosis   and   differential   diagnosis, 
506. 

etiology,  505. 

symptoms,  506. 

treatment,  507. 
Pseudo-perityphlitis,  453. 
Pus  in  fajces,  64,  95,  117,  269,  311,  319, 
496,  500. 

significance  of,  in  the  history,  64. 
Putrefaction,  intestinal,  45. 

bacteria  in,  45. 

of  carbohydrates,  46. 

of  cellulose,  46. 

of  fats,  46. 

of  Proteids,  45. 

products  of,  in  the  urine,  132. 

remedies  against,  199. 


LIST   OF   SUBJECTS 


Kandkoth,  76,  363. 

lleaetion,  Rosenbach's,  133,  366. 

Keetura,  16. 

anatomy  of,  17,  18. 

carcinoma  of,  318;   appetite  in,  319; 
ballottement,  319  ;  cachexia,  319  ; 
complications,  330  ;  diagnosis,  330 ; 
differential  diagnosis  between  car- 
cinomatous  and   syphilitic   stric- 
ture, 331;  diet,   334;   digital  ex- 
ploration, 319;  evacuations,  318; 
metastases,  330;  pain,  319;  palli- 
ative    treatment,    323;     surgical 
treatment,  326:   symptoms,   318; 
tenesmus,  319  ;  tumour,  319. 
diet  in  diseases  of,  156. 
diseases  of,  482. 
examination    of.      See    Examination, 

Rectal, 
fissures  of.    See  Fissures,  Rectal, 
fistula  of.     See  Fistula,  Rectal, 
histology  of,  19. 
illumination,  electric,  80. 
inspection  of,  77. 
myoma  of,  337. 
paralysis   and    paresis   of,   530.      See 

Paralysis,  Rectal, 
polypi  of,  335. 

prolapse  of,  505.   See  Prolapse,  Rectal, 
stricture  of,  498 ;  diagnosis,  500 ;  dif- 
ferential diagnosis,  501 ;  etiology, 
498;    palliative    treatment,    502 
surgical     treatment,     504,     505 
symptoms,    500;    syphilitic,   499 
varieties  of,  499. 
support,  508. 

ulcers  of,  494 ;  diagnosis,  496  ;  dysen- 
teric, 494 ;  etiology,  494  ;  follicular, 
494 ;  gonorrhoeal,  496  ;  symptoms, 
496 ;    syphilitic,   495 ;    treatment, 
497 ;   tuberculous,  494 ;    varieties 
of,  494. 
Remedies,  mechanical,   170 ;  in  chronic 
constipation,    348 ;    in    intestinal 
obstruction  and  stenosis,  413. 
medicinal,   186 ;    antidiarrhceal,    190 ; 
antiputrefactive,  199 ;  contraindi- 
cations,  194;  for  flatulence,  196; 
indications  for,  191 ;  sedative,  194 ; 
tonic,  198. 
Reactions.     See  Test. 
Rectoscope,  Herzstein's,  80. 


Rigidity,  intestinal,  09,  310,  345,  356. 
Röntgen  rays,  88. 

Saccharomyces  in  faeces,  119. 
Salts,  inorganic,  in  fasces,  43, 
Sarcina,  in  faeces,  119. 
Sarcoma,  intestinal,  339. 
diagnosis,  333. 
duration  of,  331. 
frequency,  339. 
location,  339. 
metastases,  331. 
relation  to  tuberculosis,  331. 
symptoms,   331 ;   absence  of  stenosis, 
331 ;   cachexia,  333  ;  gastro-intes- 
tinal  disturbances,  331 ;  intestinal 
paralysis,  331 ;  oedema  of  ankles, 
333;  rapid  growth,  331. 
treatment,  333. 
tumour  in,  330,  331. 
varieties  of,  330. 
Schafkoth,  93,  319. 
Sedatives,  194;  indications  for  the  use  of, 

195,  413,  418. 
Sensations,  subjective,  66, 
Sensitiveness,   pressure,   73.     See    Pres- 
sure Sensitiveness. 
Sigmoid  flexure.     See  Flexure. 
Sigmoiditis,  473. 
acute,  473  ;  symptoms,  473  ;  treatment, 

474. 
chronic,  474 ;   symptoms,   474 ;   treat- 
ment, 475. 
Sign,  adhesive,  Gersuny's,  77. 
Signe  de  dance,  388. 
Skatol,  43,  44,  94. 

determination  of,  in  faeces,  110. 

Skolikoiditis,  430.     See  Appendicitis. 

Soaps,  calcium,  42. 

fatty,  103,  125. 

magnesium,  43. 

Solitary  follicles,  9. 

Sounds,  rectal,  81.    See  Bougies,  Rectal, 
splashing,  73,  303,  539 ;  conditions  ne- 
cessary to  produce,  73  ;  method  of 
determination,  74  ;  significance  of, 
73,  74. 
suecussion,  74. 
Spasm,  anal,  491.     See  Fissure,  Rectal. 
Speculum,  rectal,  79. 
cylindrical,  80. 
Czerny's,  79. 


554 


DISEASES  OF   THE  INTESTINES 


Speculum,  rectal,  Herzstein's,  80. 

introduction  of,  80. 

Kelly's,  80. 

Simon's,  79. 

Sims's,  79. 
Sphincter  ani,  18. 
Spray,  ether,  in  constipation,  250. 
Steapsin,  28. 
Stenosis,  intestinal,  342. 

chronic,  diet  in,  150. 

from  duodenal  ulcer,  292. 

inflation,  rectal,  in,  85. 

percussion,  abdominal,  in,  86. 

symptoms,  343 ;  constipation,  344 ;  di- 
arrhoea, 344 ;  evacuations,  92,  345  ; 
gastric  disturbances,  344 ;  meteor- 
ism,  344 ;  pain,  344  ;  stasis,  344  ; 
visible  peristalsis,  345;  vomiting, 
355. 

treatment,   412;   diet,   150,   412;   me- 
chanical,   413  ;     medicinal,    413 ; 
surgica,l,  414. 
Stenosis  of  large  intestine,  354. 

differential  diagnosis,  357. 

etiology,  357. 

symptoms,  354  ;  colic,  354  ;  constipa- 
tion, 354 ;  evacuations,  357 ;  gastric 
disturbances,  355 ;  meteorism,  355  ; 
visible  peristalsis,  356 ;  vomiting, 
355. 

treatment.    See  Stenosis,  Intestinal. 
Stenosis  of  small  intestine,  346. 

diagnosis  of  location  and  cause,  354. 

differential  diagnosis,  353. 

duodenal,  346.  See  Duodenum,  Steno- 
sis of. 

jejunal  and  ileal,  352 ;  causes,  352 ; 
diagnosis,  353 ;  frequency,  352 ; 
symptoms,  352. 

treatment.    See  Stenosis,  Intestinal. 
Stomach  contents  in  intestinal  diseases, 
129. 

bile  in,  130. 

in  carcinoma  of  large  intestine,  311. 

in  duodenal  carcinoma,  302,  304. 

in  stenosis  of  the  small  intestine,  349. 

pancreatic  juice  in,  130. 
Stones,  faecal,  112. 

gall-.  111. 

intestinal  obstruction  by,  399. 

pancreatic,  112. 
Stools.    See  also  Fteces. 


Stools,  acholic,  94 ;  causes  of,  105 ;  deter- 
mination of,  in  ffeces,  109  ;  diag- 
nostic significance  of,  105  ;   with- 
out icterus,  104. 
fatty,  102 ;  causes  of,  103. 
in  acute  enteritis,  207. 
in  carcinoma  of  large  intestine,  310. 
in  catarrh  of  large  intestine,  222. 
in  catarrh  of  small  intestine,  219. 
in  chronic  enteritis,  216. 
in  hemorrhoids,  512. 
in  intestinal  stenosis  and  obstruction, 

345,  349,  357,  380,  388. 
in  membi-anous  enteritis,  234. 
in  mucous  colic,  540. 
in  nervous  diarrhoea,  534,  539. 
in  rectal  carcinoma,  319. 
in  rectal  strictures,  500. 
in  rectal  ulcers,  496. 
lienteric,  222. 
Strangulation,  by  internal  hernise,  373. 
by  isolated  intestinal  adhesions,  370. 
by  Meckel's  diverticulum,  373. 
by  omental  bands,  372. 
of  hemorrhoids,  512. 
through  clefts  and  fenestra,  372. 
treatment  of,  432. 
Stricture,  internal  intestinal,  395. 
causes,  395. 
diagnosis,  396. 

intestinal,  342.     See  Stenosis, 
symptoms,  396. 
Stricture,  rectal,  498. 
diagnosis,  500. 
differential  diagnosis,  501. 
etiology,  498. 
symptoms,  500. 
treatment,  502. 
palliative,  502. 

bougies,  503 ;  cathartics,  503. 
irrigations,  503. 
surgical,  504,  505. 
Substances,  inorganic,  in  faeces,  113. 
Succussion  sound,  74. 
Support,  rectal,  508. 
Suprapapillary  carcinoma  and  stenosis. 

See  Duodenum. 
Surgical  treatment.     See  Individual  Dis- 
eases. 

Teeth,   in   relation   to    gastro-intestinal 
catarrh,  67. 


LIST  OF   SUBJECTS 


555 


Temperature,  types  of,  in  acute  appendi- 
citis, 443. 
Tenesmus,  65. 

in  cancer  of  large  intestine,  808. 

in  intussusception,  388. 

in  rectal  diseases,  483,  496,  500,  512, 
532. 

significance  of,  as  a  symptom,  65. 
Test  lavage,  87. 

diagnostic  value  of,  87,  218,  219, 

technic,  87. 
Test,  Chvostek's,  284. 

digestion,  110. 

Fleischer's,  108. 

Gmelin's,  108. 

hsemin,  106. 

Hoyer-Ehrlich's,  118. 

Huppert's,  107. 

Mehu's,  207. 

Pettenkoffer's,  108. 

Rieder's,  116. 

Rosenbach's,  133,  366. 

Schmidt's,  108. 

urobilin,  107. 

Weber's,  106. 

Widal's,  120,  210,  453. 
Thymol  water,  101. 
Tongue,  in  intestinal  diseases,  67. 
Tonics,  intestinal,  198. 
Tormina   intestinorum  nervosa,  33,   68, 
524. 

diagnosis,  527. 

etiology,  524. 

symptoms,  524. 

treatment,  196,  524. 
Toxins,  in  acute  enteritis,  206. 
Trans-illumination,  electric,  88. 
Treatment,  mechanical,  medicinal,  sur- 
gical.    See  Individual  Diseases. 
Trypsin,  27. 
Tryptophan,  27. 
Tube,  electric  rectal,  173. 
Tuberculosis,  intestinal,  262. 

ileo-cfecal,  271 ;  diagnosis,  276 ;  diag- 
nosis fi'om  carcinoma  of  caecum, 
277 ;  prognosis,  272 ;  symptoms, 
272 ;  treatment,  278. 

ulcers  in,  263. 
Tumours,  intestinal,  74,  296. 

benign,  333;  adenoma,  333:  lipoma, 
335 ;  myoma,  335 ;  polypi,  333. 

consistency  of,  76. 


Tumours,  intestinal,  diagnosis  of  nature 
and  situation,  75. 

diet  in,  146. 

fajcal,  76,  245 ;  diagnosis  of,  76,  410 ; 
frequent  source  of  error,  76 ;  ob- 
struction by,  402. 

fragments  of,  in  the  fasces,  64,  99,  311. 

frequency  of,  74. 

ileo-cajcal,  271,  312. 

in  carcinoma  of  large  intestine,  309. 

in  circumpapillary  cancer,  306. 

in  intussusception,  389. 

in  suprapapillary  cancer,  302. 

malignant,  296;  carcinomatous,  296; 
sarcomatous,  329. 

palliative  treatment,  323. 

relative  mobility  of,  75. 

respiratory  mobility  of,  76. 

sarcomatous,  330. 

sensitiveness  of,  76. 

size,  variations  in,  76. 

surgical  treatment  of,  325. 

tuberculous,  264. 
Tympanites,  59.     See  Meteorism. 
Typhlitis,  430. 

diagnosis,  438. 

diet  in,  154. 

etiology,  432. 

existence  of,  431. 

stercoral,  431. 

symptoms,  432,  438. 

treatment,  450. 

Ulcer,  duodenal,  280. 

abscess  in,  291. 

alcoholism  as  a  factor  in,  283. 

carcinomatous,  293. 

complications,  291. 

diagnosis,  286. 

diet,  143,  293. 

diiferential  diagnosis,  289  ;  from  chole- 
lithiasis, 290 ;  from  gastric  ulcer, 
289  ;  from  hyperacidity,  289. 

etiology,  280. 

gastric  juice  in,  280. 

hfematemesis,  285. 

icterus,  286,  292. 

intestinal  hemorrhage  in,  285. 

location  of,  283. 

pain  in,  284. 

perforation  of,  291. 

stenosis  from,  292. 


556 


DISEASES  OP  THE  INTESTINES 


Ulcer,  duodenal,  symptoms,  283. 

treatment,  293. 

vomiting  in,  285. 
Ulcers,  intestinal,  261. 

amyloid,  266. 

catarrhal,  261. 

decubital,  262. 

diagnosis,  272. 

diet  in,  143,  145. 

dysenteric,  266. 

embolic,  267. 

evacuations  in,  268. 

follicular,  261. 

hemorrhage  from,  269. 

large  intestinal,  273. 

purulent  evacuations  in,  270. 

small  intestinal,  273. 

stercoral,  262. 

symptoms  of,  267. 

syphilitic,  266. 

thrombotic,  267. 

treatment,  277. 

tuberculous,  263. 

varieties  of,  261. 
Urine,  in  intestinal  diseases,  132. 

abnormal  substances  in,  132. 

ethereal  sulphuric  acids  in,  134. 

importance  of  examination  of,  132. 

in  acute  enteritis,  209. 

in  intestinal  cancer,  301. 

in  obstruction,  365. 
Urobilin,  30,  107. 

determination  of,  in  faeces,  107. 

Valve,  ileo-csBcal,  13. 

insufficiency  of,  529. 
Villi,  intestinal,  7. 
Volvulus,  376. 

diagnosis,  382. 

etiology,  376. 

frequency,  376,  378,  379. 

indicanuria,  383. 

injection  of  water  in,  883. 

intestinal  inflation  in,  382. 


Volvulus  of  sigmoid  flexure,  376. 

symptoms,  379 ;  constipation,  379 ; 
evacuations,  380 ;  gastric  disturb- 
ances, 380 ;  general  condition,  381 ; 
meteorism,  381 ;  pain,  380 ;  visible 
peristalsis,  381. 

treatment,  internal,  415  ;  surgical,  424. 

varieties  of,  377. 
Vomiting,  in  carcinoma  of  large  intes- 
tine, 308. 

in  carcinoma  of  small  intestine,  303, 
307. 

in  duodenal  ulcer,  285. 

in  intussusception,  388. 

in  obstruction,  361. 

in  stenosis  of  large  intestine,  355. 

in  stenosis  of  small  intestine,  348,  352. 

in  volvulus,  380. 

stercoraceous,  361. 
von  Wahl's  symptom,  363,  376. 

Water,  injection  of,  per  anum,  86. 

diagnostic  value  of,  86,  310,  367,  382. 
Waters,  mineral,  158. 

alkaline  carbonated,  159. 

alkaline,  muriated-carbonated,  159. 

bathing,  168. 

benefits  derived  from  use  of,  158,  165. 

bitter,  162. 

calcareous,  163. 

chalybeate,  164. 

classification  of,  159. 

drinking  of,  158. 

effect  of,  upon  peristalsis,  159,  163. 

enemata  of,  165. 

free  sulphuric  acid  in,  165. 

in  chronic  enteritis,  164. 

in  constipation,  159,  161,  162,  166. 

in  diarrhoea,  163,  164,  166,  227. 

in  hemorrhoids,  515. 

in  nervous  diarrhoea,  540. 

in  postappendicitis,  460. 

muriated,  161. 

sodium  sulphate,  160. 


LIST   OF  AUTHORS 


Abel,  375. 

Abelmann,  37,  38,  39,  104. 

Abraham,  133. 

Abrahams,  455. 

Ackermann,  330. 

Akerlund,  118,  229,  235. 

Albers,  285,  431. 

Albert,  338. 

Albrecht,  336. 

Albu,  199,  200. 

Alderhot,  503. 

Allihn,  102. 

AUingham,  489,  493,  498. 

Alvazzi,  290. 

Anders,  467. 

Arnsehink,  39. 

Asch,  457. 

Aubert,  186. 

Aufrecht,  461. 

Baas,  28,  133,  301. 

Babes,  338. 

Bacon,  505. 

Baer,  483,  496,  498. 

Bäumler,  124. 

Baginski,  435. 

Balfour,  31. 

Baltzer,  330. 

Bamberger,  104,  312,  313, 

437. 
Bard,  305,  306. 
V.    Bardeleben,    291,   433, 

519. 
Bardenheuer,  327,  334. 
Barker,  423. 
V.  Basch,  35. 
Bauer,  40. 

Baumann,  45,  132,  183. 
Bechterew,  35. 


Beck,  433. 

Behrens,  262. 

Belgardt,  41. 

Bell,  164. 

Berard,  297, 

Berg,  338. 

Berggrün,  104, 105. 

V.  Bergmann,  314, 

Beriten,  386. 

Berkhan,  70. 

Bernard,  26. 

Bernstein,  26,  43. 

Bessel-Hagen,  330. 

Bidder,  26. 

Biedert,  66,  103,  221. 

Bienstock,  121, 

Billroth,  264,  326. 

Birch  -  Hirschfeld,       266, 

384. 
Bird,  238. 
Blaschko,  521. 
Blauberg,  101,  102. 
Boas,  27,  28,  43,  68,  74,  87, 

89,  94,  130, 139, 143, 159, 

170,  190,  229,   237,  259, 

348,  413,  498,  524. 
Boeck,  140. 
Böttcher,  384. 
Bokai,  146, 505. 
Bollinger,  262. 
Borchardt,  432,  436,  437, 

441,  443,  450,  453,  462, 

466. 
Bossard,  453. 
Bouchard,  199,  245,  510. 
Boucquoy,  281,   283,  285, 

286. 
Boudet,  417. 
Braam-Houkgeest,  32,  38. 


Brambillo,  281. 
Brandl,  24,  37. 
Braune,  20. 
Brieger,  45,  110,  132,  134, 

186,  206. 
Brinton,  318. 
Briquet,  361. 
Brissaud,  292. 
Bristowe,  386. 
Brosch,  352. 
Brown,  25. 
Brunton,  250. 
Bryant,  292,  434, 
Budin,  509. 

Bull,  447,  448,  455,  463. 
Bunge,  25,  47,  109. 
Burwinkel,  283,  284,  286. 
Bushe,  483,  499,  503. 

Cahn,   130,   182,  304,  348, 

416. 
Canstatt,  536. 
Carrington,  329. 
Caspersohn,  445. 
Castelain,  336. 
Cherchewski,  540. 
Chevalier,  230. 
V.  Chlapowski,  70. 
Chomel,  303. 
Christoraanos,  34. 
Chuquet,  352. 
Chvostek,    134,    284,   285, 

286. 
Clado,  433,  455. 
Claus,  331. 
Codivilla,  293. 
Cohnheim,  433. 
Colberg,  266. 
Coley,  436. 

557 


558 


DISEASES  OF  THE  INTESTINES 


Collin,  280,  281,  282,  283, 
286,  287,  291,  292. 

Conitzer,  493. 

Conrad,  481. 

Conrath,  264,  271,  278, 
279. 

Copemann,  31. 

Courmont,  305. 

Courtois,  266. 

Courvoisier,  399,  423. 

Crede,  503. 

Croizet,  481. 

Crook,  160,  164,  165. 

Cruveilhier,  280,  386,  486. 

Curschmann,  21,  22,  23, 
71,  84,  182, 183, 255,  256, 
257,  259,  367,  381,  415, 
416,  417,  420,  432,  441, 
449,  461. 

Czerny,  264,  314,  326,  327, 
328,  338. 

Czygan,  302,  303. 

Da  Costa,  228,  230. 
Damseh,  84. 
Dance,  386. 
Dauber,  34. 
Davaine,  400. 
Deaver,  463,  469,  472. 
Delfrate,  290. 
Demant,  25. 
Demme,  103. 
Dessauer,  399. 
Deucher,  40. 
Devic,  286. 
Devoto,  135. 
Dickinson,  280. 
Dieffenbach,  504. 
Dietrich,  331. 
Dieulafoy,  230. 
V.  Dittel,  519. 
Dobroklonsky,  263. 
Down,  400. 
Dragendorff,  101. 
Drasch,  9. 
Drechsel,  27. 
Dufourt,  423. 
Dumont,  25. 
Dunin,  241,  242,  251. 
Dujardin-Beaumetz,  199. 
Dunn,  433. 


Durand,  455. 
Durante,  264. 

Eakins,  253. 
Eckehorn,  435. 
Edebohls,  71,  441. 
Ehrlich,  73,  118,  271. 
Eichhorst,  40, 173. 286, 293. 
Einhorn,  H.,  430,  433,  435, 

437. 
Einhorn,  M.,  66,  91,  221, 

228,  229,  234,  236,  237, 

469. 
Eisenhart,  262,  263. 
Eisenlohr,  475,  477. 
Ellenberger,  26. 
Eisner,  119. 
Emminghaus,     241,     521, 

528. 
V.  Engel,  366. 
V.  Engelhardt,  538,  539. 
Engelmann,  33. 
Englisch,  366. 
Bngström,  333. 
Escherich,  119. 
V.   Esmarch,  18,  314,  488, 

489,  491,  492,  493,  494, 

496,  503,  508,  518. 
Esquirol,  255. 
Ewald,39,40,133,173,183, 

185,  228,  229,  250,  252, 

286,  293,  415,  453,  457, 

460. 
Exner,  35. 

Faber,  353,  396. 
Fagge,  363. 
Federn,  528,  530. 
Fellner,  35. 
Fenger,  336,  447. 
Fenwick,    365,    433,    437, 

463. 
Ferrand,  459. 
Feyat,  245. 
Fiebig,  91. 
Firth,  206. 
Fischer,  263. 
Fischl,  209. 
Fitz,    433,  435,  436,  437, 

466. 
Pleiner,  179,  227,  237,  242 


243,  255,  256,  257,  278, 

336,  338,  384,  476,  536. 
Fleischer,  39,  44,  93,  108, 

109,  209,  252. 
Fowler,  433,  441,  447,  450, 

455,  463,  467. 
Fraenkel,  A.,  441. 
Fränkel,  E.,  352,  353,  455. 
Frank,  366. 
Franke,  238. 
Frerichs,  268. 
Frey,  10. 
Frick,  25,  26. 
Friedenwald,  74. 
Friedreich,  115. 
Frikker,  400. 
Fromm,  249. 
Fürbringer,  417,  441. 

Gaffky,  205. 
Gallia"rd,  514,  555. 
Gamgee,  31. 
Gans,  149. 
Gegenbaur,  13. 
Gendron,  454. 
V.  Genersich,  85. 
Gerhardi,  304. 
Gerhardt,  104, 125, 454, 463. 
Gerster,  455. 
Gersuny,  77. 
Gibson,  423,  426. 
Gilford,  333. 
Ginsberg,  38. 
Girode,  269. 

Glenard,  229,  241, 245, 255. 
Glücksmann,  294. 
Gmelin,  108,  109,  207. 
Goldbach,  487. 
Goltdammer,  415. 
GolubefE,  436. 
Goodsir,  119. 
Graser,  407,  417,  425. 
Grawitz,  262,  463. 
Grisolle,  430. 
Grohe,  430,  432,  433. 
Gruber,  28,  453. 
Grundzach,  404. 
Grützner,  25,  34. 
Gussenbauer,  453. 
Guttmann,  375. 
Gyergyay,  37. 


LIST   OF  AUTHORS 


559 


Hadham,  290. 
de  Häen,  255. 
Hagemann,  48. 
Plagenbach,  304. 
Haguenot,  361,  3G2. 
Hahn,  314,  333,  347,  348, 

352,  503. 
Hall,  208. 
Hamann,  262. 
Harnmarsten,  103. 
Handford,  334. 
Hansemann,  298. 
Häri,  108. 
Harley,  432. 
Hartley,  440,  467,  408. 
Hartmann,   264,  313,  490, 

499. 
Hasenclever,  183. 
Hauser,  298,  299,  334. 
Hausmann,  299. 
Hedin,  27. 
Hegar,  177. 
Heidenhain,  26,  27,  31,  37, 

39,  43,  404,  418. 
Heidenreich,  400. 
Heimann,  297. 
Heineke,  327. 
Helferich,  334. 
Heller,  400. 
Hem  meter,  82. 
Henle,  10,  12,  19,  361. 
Henoch,  183,  293, 365,  389, 

435. 
Henry,  301. 
Henschen,  231. 
Herczl,  294. 
Hermann,  41,  42,  209. 
Heron,  25. 
Herter,  26. 
Hertz,  20,  21. 
Herxheimer,  262. 
Heryng,  88. 
Herz,   113,   130,  304,  348, 

349,  350,  351,  353,  529. 
Herzstein,  80. 
Heubner,  453. 
Heurteux,  338. 
Hiller,  253. 
Hirsch,  24,  36. 
Hirschler,  141. 
Hlawacek,  455. 


Hochenegg,  320,  327,  389, 

406. 
Hochhaus,  130,  348,  350. 
V.  Hochstätter,  445. 
Hoffa,  170. 
Hofmeister,   26,    37,    264, 

352,  414. 
Hofmokl,  77,  485. 
Holländer,  338. 
Holtmann,  334. 
Honigmann,  41. 
Hoppe-Seyler,  25,   37,   38, 

94,  95,  102,  103,  113. 
Hoyer,  118. 
Huber,  40,  400. 
Iluppert,  107. 
Hutchinson,  334. 
Hyrtl,  3,  18. 

Illoway,  240. 

Israel,  J.,  314, 366, 397, 404, 

453,  505. 
Iversen,  299. 

Jaccoud,  361. 

Jacob],  195. 

Jaffe,  132,  133,  365,  366. 

V.   Jaksch,  101,    102,   103, 

104,  105,   106,  110,  111, 

119,  121.  123,  125. 
Jan  icke,  305. 
Jaworski,  130,  226. 
Johnson,  353,  455. 
Jullien,  483,  496. 
Jürgens,  520. 

Kader,  48,  363. 
V.  Karajan,  338. 
Karewski,  435,    437,  441, 

442,  444,  449,  453,  466. 
Käst,  133,  301. 
Katz,  104,  105. 
Kauffmann,  100,  183. 
Kaulich,  134. 
Kelling,  393. 
Kelly,  80. 
Kelsey,  78. 
Kelynack,  438. 
Kernig,  306. 
Kirmisson,  399. 
Kitagawa,  96, 230, 234, 235. 


Kjeldahl,  101. 
Kjellberg,  209. 
Klebs,  262,  263. 
Kleinwächter,  461. 
Klemperer,  301. 
Kobert,  40,  41, 198. 
Kobler,  209,  244. 
Kocher,  344,  417,  421. 
Kühner,  497. 
König,  264,  276,  309,  326, 

372. 
Körte,  264,  326,  397,  399, 

404,  417,  433,  436,  440, 

441,  447,  450,  455,  463, 

404,  466,  503. 
Köstlein,  399. 
Kohlenberger,  40. 
Kohlstock,  253. 
Kohn,  316. 

Kossobudskji,  517,  518. 
Kraft,  455. 
Kraske,  299,  319,  320,  321, 

327,  328,  329. 
Krauss,  280,  285,  286,  292. 
Krausshold,  313,  434. 
Krönlein,  326,  432. 
Krokiewicz,  276. 
Krüger,  329,  330.  332. 
Krukenberg,  338. 
Krysinski,  230. 
Kühne,  27,  43. 
Kukula,  338. 
Kümmel,  433, 439, 447, 463, 

465. 
Küster,  183,  430. 
Küttner,  352,  363,  377. 
Kuhn,  82,  183. 
Kundrat,  329. 
Kussmaul,  36, 183.304, 356, 

416,  418,  524,  527. 

Lafforgue,  433. 
Landau,  255,  282. 
Landerer,  294. 
Lange,  294,  519. 
deLangenhagen,  228,  229, 

230. 
Langerhans,  385. 
Langermann,  238. 
Lannelongue,  510. 
Lannois,  305. 


560 


DISEASES  OF   THE  INTESTINES 


Lanz,  435. 

Lappe,  25. 

Lauenstein,  441. 

Lehmann,  25,  26,  40,  48. 

Leiehtenstern,  112,  124, 
125,  255,  303,  343,  348, 
358,  361,  367,  372,  373, 
374,  378,  379,  385,  386, 
394,  400,  403,  404. 

Lennander,  292,  294,  432, 
433,  437,  444,  450. 

Lennhof,  70. 

Leo,  83,  110,  111. 

Letcheff,  230. 

Letulle,  353. 

V.  Leube,  40,  130, 143,  177, 
228,  257,  263,  273,  286, 
290,  293,  404,  413,  474. 

Leubuscher,  173. 

Levy,  327. 

Levy-Dorn,  259. 

Lewandowski,  89. 

Lewin,  503. 

V.  Leyden,  196,  230,  323, 
441." 

Libman,  329,  332. 

Liebig,  186. 

Liebmann,  102. 

V.  Liebermeister,  251. 

Lingen,  377. 

Link,  336. 

Litten,  134,  234,  353,  362. 

Lloyd,  470. 

Ijobstein,  897,  423. 

Lockwood,  293,  338,  467, 
469. 

Lösch,  210. 

Lövinsohn,  327. 

Löwenstein,  234. 

Longuet,  234. 

Lorenz,  134. 

Louyer,  430. 

Lubarseh,  298. 

Ludloff,  426. 

Ludwig,  26,  38. 

Luschka,  334, 433. 

McArthur,  455. 
McBurney,  70,    370,    433, 

463,  466,  467,  469,  470, 

471,  472. 


McCosh,  455. 
McMurtry,  433. 
McNutt,  469. 
Macdonald,  517. 
Macfadyen,  44,  45,  73,  118. 
Mackenzie,  293. 
Maclagan,  399. 
Madelung,  330,  331,  332. 
Maisonneuve,  278,  326. 
Maixner,  134. 
Makins,  334. 
Malgaigne,  368. 
Manley,  432. 
Mannaberg,  123,  444. 
Planning,  25. 
Marchand,  231. 
Mariage,  432. 
Mars,  455. 

Mathieu,  228, 229,  230,  520. 
Matterstock,  430,  434,  435, 

436. 
Maurin,  434. 
Maydl,  297,  299. 
Mayer,  35,  285. 
Mayor,  473,  474,  478. 
Mehu,  107. 
Melchior,  262. 
Melchioris,  378. 
Melier,  430. 
Meltzer,  44. 
Mendelson,  228. 
T.  Mering,24,26,  28,  36,38, 

282. 
Messter,  133. 
Meusser,  432. 
Meyer,  L.,  395. 
Meyer,  W.,  472. 
Michel,  333. 
Mikulicz,    293,    325,    397, 

444,  463. 
Miller,  47. 
Minich,  112. 
Minkowski,  26,  37,  38,  39, 

86,  104. 
Mirallie,  306. 
Mislawski,  35. 
Miura,  25. 
Möbius,  541. 
Monod,  445. 
Moreau,  186. 
Morgagni,  255. 


Moritz,  24,  36,  282. 
Morris,  435. 
Morton,  463,  466. 
Mosler,  400. 
Mühlhäuser,  209. 
Müller,  38,  40,41,103,  104, 

125,  132,  140,  301,  331. 
Munde,  455. 

Munk,  L,  37,  38,  39,  40,  41. 
Murphy,  434,  461,  463. 
Musculus,  28. 
Mynter,  463,  469,  473. 

Nanu,  338. 

Nasse,  35,  186. 

Naumann,  443. 

Naunyn,  290, 362,  365, 382, 
397,  398,  407,  420,  422, 
423,  424,  449,  450,  510. 

Nay,  430. 

V.  Nencki,  28,  44,  45,  73, 
105,  118. 

Neumeister,  31,  39. 

Nickel,  500. 

Nicolaysen,  311,  336. 

V.  Noorden,  41,  103,  190, 
237. 

Nothnagel,  33,  33,  34,  47, 
62,  68,  69,  75,  77,  95,  96, 
97,  100,  104,  105,  106, 
109,  113,  114,  116,  121, 
123,  124,  133,  146,  173, 
181,  183,  194,  213,  216, 
217,  219,  220,  228,  230, 
235,  241,  244,  252,  268, 
273,  386,  397,  310,  315, 
339,  331,  344,  345,  355, 
356,  357,  358,  361,  365, 
383,  384,  386,  405,  406, 
407,  410,  415,  434,  430, 
433,  436,  437,  439,  445, 
453,  454,  460,  509,  510, 
522,  524,  525,  532,  540. 

Nnttal,  118. 

Nylander,  102. 

Obalinski,   363,   365,   421, 

424. 
Obrastzow,  71.  72.264,276. 
Oesterlein,  125. 
V.  Oettingen,  426. 


LIST   OF  AUTHORS 


561 


Oppenheimer,  280,283,284, 

285,  286. 
Oppler,  66,  131,  221,  227. 
Oppolzer,  468. 
Orth,  263,  266. 
Ortweiler,  132,  133,  141. 
Oser,  306,  531. 
Osier,  467,  469. 
Otto,  38. 
Ozenne,  230. 

Pacanowski,  134. 

Paci,  336. 

Pässler,  ol4. 

Paget,  334. 

Pal,  35,  476,  477,  478. 

Pariser,  100,  235. 

Paton,  31. 

Pauly,  281. 

Pawlow,  222. 

Pean,  503. 

Peiper,  400. 

Pel,  104. 

Pellizari,  338. 

Penzoldt,154,167,179,246, 

247,  248,  251,  252,  436, 

441,  442,  457,  458,  459, 

460. 
Pepper,  467,  469. 
Perewoznikoff,  39. 
Perroncito,  124. 
Perry,  280,  281. 
Petrina,  352. 
Pettenkoffer,  108. 
Petters,  134. 

Peyer,  523,  524,  5-33,  534. 
Pfannenstiel,  338. 
Pflüger,  35. 
V.  Pfungen,  133. 
Pic,  303,    304,    305,    306, 

348. 
Pick,  445,  534,  541. 
Pilliet,  264. 
Planer,  47. 
Pl(5sz,  37. 
Podolinski,  27. 
Pölchen,  500. 
Pohl,  195. 
Poisseuille,  186. 
PoUak,  183,  184. 
PoUatschek,  165. 


Port,  334. 
Porter,  432. 
Potain,  228,  311,  377. 
Power,  384,  386. 
Praussnitz,  140, 
Pravaz,  437. 
Prazmowski,  121. 
Preismann,  518. 
Prochownick,  334. 
Pulawski,  129. 

Quenu,  490,  499. 
Quincke,  93,  94,  126,  154, 

177. 

Radziejewski,  186. 
Raffinesque,  386,  389,  391. 
Ramm,  198. 
Rauber,  1,  8,  9,  10,  17. 
Reckmann,  280,  281,  285, 

286. 
Regnault-Beclard,  48,  373. 
Rehn,  327. 
Reiche,  348. 
Reichmann,  88. 
Reinbach,  511. 
Reinke,  352. 
Reisert,  48. 
Rendu,  453. 

Renvers,  434,  441,461,463. 
Rewidzofe,  348. 
Ribbert,  298,430,  433,  434, 

436. 
Richardiere,  231. 
Richardson,  250,  443,  461. 
Richelot,  313. 
Ricker,  331. 
Riedel,  394,  450,  477. 
Rieder,  116,  394,  499,  500, 

503,  505. 
Riegel,  34,  130,  348,  349. 
Roberts,  27. 
Robin,  286. 
Robitschek,  134. 
Robson,  31. 
Rochard,  399. 
Röhmann,  25,  31. 
Roesen,  134. 
Rokitansky,  297. 
Romberg,  533. 
Rommelare,  301. 


Roos,  94. 

Rosenbaeh,   84,    133,   301, 

417,  462,  527. 
Rosenheim,  228,  247,  248, 

252,  474,  514,  518,  527, 

534,  541. 
Rosenstein,  38,  39,  40,  47, 

361. 
Rosi,  338. 
Rosin,  133. 
Rossbach,  43. 
Rothmann,  229,  231,  235. 
Rotter,  433,  437,  439,  443, 

446,  447,  450,  454,  458, 

461,  462,  463,  464,  465, 

504,  505. 
Roux,  286,  433,  441,  519. 
Rovighi,  199. 
Rubner,  39,  99,  139,    140, 

141. 
Rüpp,  297,  299,  307,  308, 

311,  312,  326. 
Rüge,  47,  229. 
Rumpel,  133. 
Runeberg,  84. 
Ruysch,  255. 
Rydygier,  424,  426. 

Sahli,  154,  200,  412,  431, 
436,  441,  457,  461,  463. 

Salkowski,  40, 45,  132,  133, 
135. 

Salzer,  264,  278,  314. 

V.  Samson,  22. 

Sanders-Ezn,  32. 

Sandmeyer,  37,  40,  104. 

Sandowski.  516. 

Sandoz,  404. 

Sands,  466. 

Sappey,  8,  9,  11,  15. 

Sasaki,  521. 

Searbinato,  254. 

Schäfer,  198. 

Schede,  313,  364,  421,  426, 
433,  463,  505. 

Schiefferdeeker,  22. 

Schierbeck,  47. 

Schillbach,  173. 

Schlange,  327,  363,  365. 

Schleimpflug,  521, 

Schloffer,  326. 


562 


DISEASES  OP  THE  INTESTINES 


Schmidt,  Ad.,  97, 108,  117, 
319,  235. 

Schmidt,  C,  26, 98,  99, 100. 

Schmidt,  R.,  331,  332. 

Schmitz,  199. 

Schnetter,  89. 

Schneyer,  301. 

Schnitzler,  365,  395,  408. 

Schreber,  249. 

Schrötter,  293. 

Schuchardt,  503. 

Schule,  130,  348,  350. 

Schüler,  423. 

Schulze,  281. 

Schuster,  70. 

Schwab,  334. 

See,  70,  228,  230. 

Senator,  40,  132,  183,  453, 
463. 

Senn,  338,  447,  448. 

Shaw,  280,  281. 

Sheild,  280,  290,  451, 

Sick,  399. 

Sieber,  44,  45,  73,  118. 

Simon,  79,  86,  400. 

Siredey,  228. 

Skliffassowski,  338. 

Small,  436. 

Smith,  334. 

Sonnenburg,  153,  433,  435, 
437,  439,  440,  441,  445, 
446,  447,  450,  451,  452, 
462,  463,  464,  466,  504. 

Soulier,  517. 

Stadelmann,  29,  125. 

Starke,  285. 

Stein,  468. 

Steiner,  336,  337,  436. 

Stiller,  209. 

Stöhr,  6,  7. 

Stokes,  403. 

Strauss,  47,  148,  404. 

Strehl,  404. 

Stromayr,  134. 

Strümpell,  209. 

Subbotin,  198. 

Suffit,  266. 

Swiezynski,  34. 

V.  Sydow,  434. 

Tacke,  48,  363. 


Talamon,  430, 431, 436, 445, 
453. 

Talma,  522. 

Tappeiner,  47. 

Tavel,  435. 

Teichmann,  40,  104. 

Terrillon,  454. 

Thiem,  504. 

Thierf  elder,  103,  113,  118. 

Thiersch,  298. 

Thiry,  25. 

Thomas,  384. 

Tietze,  365. 

Tiffany,  469. 

Treub,  455. 

Treves,  57,  306,  309,  310, 
330,  360,  361,  362,  370, 
372,  373,  379,  380,  381, 
382,  386,  389,  390,  391, 
392,  393,  399,  406,  417, 
421,  433,  434,  437,  441, 
445,  447,  460. 

Trommer,  102. 

Trousseau,  503,  534. 

Tschitschowisch,  263. 

Tuffier,  433. 

Turby,  25. 

Turner,  209. 

Tyson,  469. 

Ullmann,  234. 
Unna,  517. 

V.  Vämossy,  195. 

Vanni,  229. 

Vanvers,  445. 

Varr,  408. 

Vaughan,  206. 

van  den  Velden,  46. 

Verneuil,  518. 

Virchow,  96,  255,  270,  298, 

394,  496,  502. 
Villerraay,  430. 
Vötsch,  244,  255. 
Voit,  30,  40,  42. 
Volz,  437,  458. 
Vries,  133. 

Wagner,  84. 

V.  Wahl,  363,  364,  381, 
407. 


Waldeyer,  298. 
Wallis,  353. 
V.  Walther,  39. 
Walton,  164. 
Wannach,  294. 
Wassiljeff,  94. 
Weber,  106. 
Weecke,  304. 
Wegele,  247,  248,  348. 
Weir-Mitchel,  259. 
Weiske,  140. 
Wendt,  34. 
Wenz,  26. 
Wernich,  352. 
Westphalen,  393. 
White,  238. 
Whitehead,  334,  520. 
Wiczkowski,  252. 
Widal,  120,  210,  453. 
Wiedersheim,  39. 
Wieland,  463. 
Weir,  466. 
Wiener,  469. 
V.  Wild,  247,  250. 
Will,  39. 
Williams,  250. 
van  der  Willigen,  493. 
Wilms,  304,  348,  365. 
Windscheid,  475. 
Winston,  31. 
Winternitz,  199. 
Wittich,  110. 
Wittstock,  279. 
Wölfler,  325,  326,  338,  445. 
Wollbrecht,  480. 
Wood,  253. 
Woodward,  43. 
Wunderlich,  311. 
Wyss,  262. 

Zander,  172. 

Zawadsky,  26. 

Zawarykin.  39. 

Zemann,  296. 

Ziegler,  266. 

V.  Ziemssen,  84,   86,   173, 

333,  417. 
V.   Zöge  -  Manteuffel,   363, 

364,  365. 
Zuckerkandl,  430,  436. 
Zuntz,  48,  363. 


A  TEEATISE 

ON"   DISEASES   OE   THE 

RECTUM,  AI^US,  a^d 

SiaMOID  FLEXURE. 


By  JOSEPH  M.  MATHEWS,  M.D., 

of  louisville,  kt., 

Professob  of  the  Peinciples  and  Peactice  of  Surgery,  and  Clinical  Lectceeb 

ON  Diseases  of  the  Rectum,  in  the  Kentucky 

School  of  Medicine,  etc. 


With  Six  Cliroinolithographs  and  numerous  Illustrations  in  the  Text. 
SECOND  EDITION,   REVISED. 

8vo,  537  pages.     Cloth  binding,  $5.00. 


SOLD  ONLY  BY  SUBSCRIPTION. 


"  The  author  has  placed  before  the  profession  the  fruits  of  fifteen  years'  experience  as  a 
rectal  specialist.  ...  A  careful  perusal  of  Mathews's  work  can  not  fail  to  give  the  practi- 
tioner all  the  knowledge  that  is  desirable  to  successfully  diagnosticate  and  treat  any  case  of 
rectal  disease  that  may  come  before  him,  if  he  possesses  a  modicum  of  the  dexterity  that  an 
ordinary  surgeon  should  have.  .  .  .  The  book  is  rich  in  clinical  material,  and,  in  the  writer's 
opinion,  is  the  best  work  on  this  specialty  yet  published.  The  publishers  have  done  their 
work  well,  the  six  chromolithographs  being  artistic." — Chicago  Medical  Recorder, 

"._  .  .  The  work  is  a  most  practical  and  classical  presentation  of  the  vast  and  varied 
experience  of  a  painstaking  observer  and  worker.  The  specialist  will  buy  it  and  read  it, 
otherwise  he  would  not  be  progressive.  The  general  practitioners,  above  all,  should  procure 
and  read  this  book,  for  the  reason  that  it  will  at  least  assist  them  in  making  a  correct 
diagnosis ;  and,  if  they  care  to  treat  these  diseases,  it  gives  them  all  that  is  newest  and 
best." — Medical  Mirror. 

"  This  book  we  think  is  decidedly  original  in  many  of  its  features.  The  author  has  not 
taken  other  men's  opinions  as  his  guide,  for  the  reason  that  in  his  fifteen  years'  experience 
as  a  rectal  specialist  he  has  learned  '  that  many  things  that  are  taught  are  not  true,  and  that 
many  true  things  have  not  been  taught.'  He  has  therefore  accepted  as  truths  only  those  things 
which  could  be  substantiated  by  facts,  and  has  here  recorded' them.  Several  chapters  new 
to  books  on  this  subject  have  been  introduced  by  him,  among  which  wül  be  found  the  follow- 
ing :  Disease  in  the  Sigmoid  Flexure,  the  Hysterical  or  Nervous  Eectum,  Anatomy  of  the 
Rectum  in  Relation  to  Reflexes,  Antiseptics  in  Rectal  Surgery,  and  a  New  Operation  for  Fistula 
inAno.  .  ,  .  Illustrated  with  six  excellent  colored  plates  and  numerous  cuts  ;  clearly  printed 
with  large  type,  and  nicely  bound,  it  presents  a  most  attractive  appearance.  We  do  net 
know  of  any  work  on  the  subject  wMgii  more  thoroughly  meets  our  approval." — Memphis 
Medical  Monthly. 

D.   APPLETO]!^   AND    COMPANY,  NEW  YORK. 


A  TREATISE  ON  THE 
DISEASES   OF  WOMEN. 

By  ALEXANDER  J.    C.    SKENE,  M.  D., 

PROFESSOR    OF    GYNECOLOGY    IN  THE  LONG    ISLAND  COLLEGE    HOSPITAL,   BROOKLYN,    N.  Y.  ;    FOR- 
MERLY   PROFESSOR    OF    GYNECOLOGY    IN    TEE    NEW    YORK    POST-GRADtTATE    MEDICAL 
SCHOOL    AND    HOSPITAL,    ETC. 


Third  Edition,  revised  and  enlarged.     8vo,  991  pages.     With  290  Fine 

Wood  Engravings,  and  Nine  Chromolithographs,  prepared 

especially  for  this  work. 

SOLD  ONLY  BY  SUBSCRIPTION. 

THIS  attractive  work  is  the  outcome  and  represents  the  experience  of  a  long  and 
active  professional  life,  the  greater  part  of  which  has  been  spent  in  the  treat- 
ment of  the  diseases  of  women.     It  is  especially  adapted  to  meet  the  wants 
of  the  general  practitioner,  by  enabling  him  to  recognize  this  class  of  diseases  as 
he  meets  them  in  every-day  practice  and  to  treat  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in  their  natural 
order,  and  thus  are  more  easily  comprehended  and  remembered  by  the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in  his  practice, 
and  it  has  been  his  endeavor  to  so  describe  the  operative  procedures  adopted  by 
him,  even  to  their  minutest  details,  as  to  make  his  treatise  a  practical  guide  to  the 
gynaecologist. 

While  attention  has  been  given  to  the  surgical  treatment  of  the  diseases  of 
women,  and  many  of  the  operations  so  simplified  as  to  bring  them  within  the 
capabilities  of  the  general  surgeon,  due  regard  has  also  been  paid  to  the  medical 
management  of  this  class  of  diseases. 

■  Although  all  the  subjects  which  are  discussed  in  the  various  text-books  on 
gynecology  have  been  treated  by  the  author,  it  has  been  a  prominent  feature  in 
his  plan  to  consider  also  those  which  are  but  incidentally,  or  not  at  all,  mentioned 
in  the  text-books  hitherto  published,  and  yet  which  are  constantly  presenting 
themselves  to  the  practitioner  for  diagnosis  and  treatment. 

"In  the  preface  of  the  first  edition  of  this  work  the  author  states  :  'This  work  was  written  for 
the  purpose  of  bringing  together  the  fully  matured  and  essential  facts  in  the  science  and  art  of 
gynsecoloo-y,  so  arranged  as  to  meet  the  requirements  of  the  student  of  medicine,  and  be  convenient 
to  the  practitioner  for  reference.'  The  demand  for  a  second  edition  has  demonstrated  how  fully 
this  purpose  has  been  accomplished.  The  reader  can  not  fail  to  commend  the  conservatism  and 
honesty  of  the  author 's  opinions,  and  the  care  with  which  the  material  has  been  collected  and 
arranged.  The  second  edition  contains  new  chapters  on  Ectopic  Gestation,  Diseases  and  Injuries 
of  the  Ureters,  and  Vesical  Hernia.  The  first  of  these  subjects  receives  in  this  edition  a  careful 
exposition,  the  want  of  which  was  among  the  few  defects  of  the  former  edition.  The  author's 
work  in  the  positional  disorders  of  the  uterus  and  laceration  of  the  perinasum  stands  pre-eminent 
among  the  contributions  to  this  subject.  His  discussion  of  the  use  of  pessaries  throws  much  light  upon 
a  subject  which  has  suffered  from  the  want  of  caretul  treatment,  both  pro  and  cow.  The  publishers 
deserve  great  credit  for  the  illustrations  and  general  style  of  the  woti^s..'''— Medical  News. 

"We  have  very  little  to  add  to  what  we  said  of  it  on  its  first  appearance,  and  we  still  regard  it  as 
one  of  the  few  foremost  books  in  this  department  in  the  English  language.  The  addition  of 
chapters  on  Diseases  and  Injuries  of  the  ureters,  and  on  Ectopic  Gestation,  make  it  more  complete. 
Too  much  praise  can  not  be  given  to  the  illustrations,  which  are  models  of  clearness,  and,  as  is  not 
always  the  case,  show  what  is  meant." — Boston  Medical  and  Surgical  Journal. 


D.  APPLETON   AND   COMPANY,  NEW  YORK. 


